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Balloon Sinuplasty is an endoscopic surgical technique where a small, flexible balloon catheter is used to open up blocked sinus passages thereby facilitating the drainage of the mucus built-up. Balloon Sinuplasty is often used in cases of severe rhinosinusitis and has revolutionized sinus surgery as it is highly efficient and also cost effective.
The first Balloon Sinuplasty was carried out in the US in 2004, and in just a few years the total number of patients treated this way reached 30,000. The reasons for such a quick expansion are simple – it works, it’s safe, and the technology is widely available (and affordable!).
We will jump into the details of this kind of surgery later, but for now, let’s just say that a surgeon uses sophisticated instruments with inflatable balloon-like structures on the top to widen the sinus openings in the nasal cavity.
The principle of the balloon dilatational surgery found its application in various fields of medicine, not only ENT. ENT specialists ‘borrowed’ it from vascular surgeons – balloon dilation is used to resolve all kinds of narrowings in blood vessels throughout the body, and has been around for quite long. However, it turned out to be particularly useful in resolving common structural abnormalities in the nasal cavities of patients with chronic rhinosinusitis as well.
The surgical management of sinusitis went through a rough path in the last 100 years, with two giant leaps that made a huge difference in outcomes. The first one was the introduction of functional endoscopic sinus surgery (FESS) back in the 1970s and the second was the Balloon Sinuplasty in 2004. According to many authors, Balloon Sinuplasty took Sinus surgery a step further. FESS remains to be a method of choice for certain categories of patients, but a significant percentage of patients treated this way, now undergo a lot quicker and less invasive Balloon Sinuplasty surgery.
Reasoning behind the technique
When talking about chronic rhinosinusitis and improvements made with FESS and Balloon Sinuplasty, we cannot avoid mentioning the contributions of Austrian doctor, Professor Walter Messerklinger. Without his observations of Sinus function and physiology, ENT care would still be stuck at Sinus obliteration as the only option for stubborn chronic rhinosinusitis. The obliteration was a rather harsh surgical technique of literally crushing the sinus cavity, destroying it and leaving behind a lump of connective tissue and bone (not to mention the approach through forehead).
Professor Messerklinger is the founding father of modern endoscopic ENT surgery. Balloon Sinuplasty as well relies exclusively on the principles he established. These include discovery and description of rather complex laws of sinus drainage. The mucus produced in the sinuses has a well-defined flow that doesn’t change substantially over time in healthy individuals. The lining inside and around the sinus cavities is what keeps the flow going. This is why scarring in the area and damage to the lining inside and around sinuses can permanently damage the drainage principles, pushing the patient towards lifelong rhinosinusitis.
In a nutshell, it all comes to preserving as much sinus lining as possible during surgery – because an intact lining means proper sinus drainage. Although this principle might sound like a simple instruction, it wasn’t easy to follow it until the introduction of Balloon Sinuplasty. The damage to the lining during the intervention (if any of it occurs) is negligible, and that is what makes it so effective.
Balloon Sinuplasty is usually performed in the ENT Hospital under local anesthesia. Sometimes, the ENT surgeon decides to carry it out under general anesthesia in the Operation Room. Generally speaking, patients with pronounced structural abnormalities of the nasal cavity need to undergo the latter.
The procedure is carried out through the nostril, so it doesn’t leave any incisions or scars behind. The instrument consists of guide catheters, a dilation balloon, and an irrigation catheter. The goal is to insert the instrument through the sinus ostia and reach the cavity that way. Ostia are small openings inside the nasal cavity that connect the sinuses with the nose and rest of the respiratory tract.
Prior to surgery, nasal decongestants are applied to reduce the swelling of nasal lining and loosen up the ostia a little bit. This helps the surgeon to reach the sinus cavity easier. Also, by using nasal decongestants, the risk of lining tears and bleeding is reduced to the minimum. Despite all precautions, low-intensity bleedings sometimes happen. They are not dangerous, and in most cases resolve within a few hours without additional interventions. The lining heals very fast.
Epithelial cells – building blocks of the lining – repair through a process known as Epithelization. Even in cases of extensive damage (which never happens during Balloon Sinuplasty), epithelization occurs within four days.
The procedure starts by placing the instrument (guide catheter) into the nostril and by identifying sinus ostia that connects sinus with the nasal cavity. Then, the surgeon gently pushes the catheter through the ostia and accesses the sinus cavity. The folded deflated balloon at this stage is advanced through the narrowed ostia.
The surgeon slowly inflates the balloon. As it expands, it compresses the surrounding (swollen) lining and widens (dilates) the ostia. After sufficient dilation has been achieved, the surgeon deflates the balloon.
The surgery doesn’t end here – through the irrigation catheter, the surgeon injects a saline solution rinsing the mucus and pus that builds up in the sinuses over time. After the rinsing, the surgeon removes the instrument from the sinus leaving it to drain spontaneously in the days to come.
Often, the procedure is carried out on more than one cavity as chronic rhinosinusitis has a tendency to affect multiple sinuses at once.
Although this might sound like a simple procedure, actually, it requires a lot of skill and patience, since the ostia might be tightly narrowed down making the insertion of the instrument into the ostia very difficult. To illustrate the challenge in simple words, it’s like trying to thread the needle using a thread that’s almost too big to come through. From a distance of three feet. Using a non-dominant hand. Not impossible, but requires exceptional patience and skill.
The weak spot of Chronic Rhinosinusitis only Balloon Sinuplasty can fix
Unlike acute inflammatory response which is a self-limiting and healthy reaction to injury or infection, chronic inflammation can go on forever, and it’s never a good thing. This principle applies to the entire body and all diseases, so chronic rhinosinusitis is no exception.
The condition can rage with various levels of activity throughout a patient’s entire life. The local immune response results in increased blood flow, which then cause swelling of the lining. As it enlarges, canals that connect sinuses with nasal cavity close up and the buildup of mucus, pus, and microorganisms in the cavity begins. The fluid inside the sinus fuels the fans of inflammation which over time turns into chronic rhinosinusitis – a condition that doesn’t have a tendency to resolve on its own.
Balloon Sinuplasty resolves the root of chronic rhinosinusitis – it re-establishes the physiological drainage pathways by reopening the communication canals. Once the ‘reservoir of inflammation’ made of mucus, pus and microorganisms is drained, inflammation quickly resolves. Re-opening is just one part of the solution.
The key component of successful treatment is scarring of the lining. The scarring that obsolete surgical techniques used to leave behind is the sole reason why rhinosinusitis surgery had poorer outcomes than Balloon Sinuplasty.
Recovery time after Balloon Sinuplasty is short. While a majority of patients manage to go back to their normal activities within a couple of days, for some, the recovery might take longer, but never more than 5-7 days. Blowing the nose for at least 24 hours after the surgery is prohibited. Physical activity needs to be avoided, as well as straining during bowel movement or urinating in the first 7 days.
Some patients experience congestion, fatigue and the feeling of stuffed nose during the first post-op week and that is normal. The drainage from the sinuses might be slightly unpleasant and voluminous in the first 7 days, but this is normal since the entire nasal cavity is irritated by the intervention.
Typically, patients get an antibiotic to discourage infection, a saline solution to rinse the nasal cavity and pain relievers just in case (the recovery is rarely painful). Patients need to follow instructions provided by their doctor strictly. Bottom line…recovery is quick, painless and patients rarely report any problems during this period.
Good candidates for surgery
The ENT specialist tailors the treatment to each patient individually and makes the decision whether or not he or she is a good candidate for Balloon Sinuplasty. Generally speaking, patients with minor structural abnormalities of the nasal cavity and an absence of polyps are good candidates for the surgery. In other words, the majority of the patients. Of course, surgery is never the first treatment choice for chronic rhinosinusitis – it comes into play only after conservative therapy fails.
Radiologic imaging techniques come handy here. The CT examination helps to clear all doubts about whether or not the patient can undergo the procedure. In cases of benign or malignant tumors, significant structural anomalies or scarring from previous operations, the procedure is contraindicated.
Unfortunately, not all patients with chronic rhinosinusitis are good candidates for Balloon Sinuplasty. However, those not suitable for this kind of surgery can benefit from other techniques such as FESS.
Studies regarding the efficacy and safety of the procedure
Plenty of scientific evidence accumulated over the recent years clearly demonstrate the benefits and safety of Balloon Sinuplasty.