Abstract
Balloon sinus dilation is a tool of widespread use in the surgical management of chronic rhinosinusitis. Balloon dilation of a sinus may be done with or without concurrent dissection of inflamed sinus mucosa and bone. However, only the maxillary, frontal, and sphenoid sinuses are amenable to this technique. A thorough preoperative evaluation is necessary including special attention to anatomic variants that may make the use of the balloon dilation catheter more difficult. Of particular importance is the degree of ethmoid inflammation present as this cannot be directly addressed with any isolated balloon procedure. Various balloon devices are available, but the technology mainly relies on the illumination of the sinus with a light versus tracking of the balloon catheter tip under stereotactic image guidance. Upon introduction of the guide catheter, the balloon can be inflated to open the sinus outflow tract. Normal postoperative care should be considered, including management of the underlying chronic inflammatory disease.
Keywords
balloon sinuplasty, balloon sinus dilation, chronic rhinosinusitis
Introduction
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Balloon sinus dilatation is a surgical technique that widens the natural sinus ostium using a balloon catheter.
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Balloon sinus dilatation has been used to address the maxillary, sphenoid, and frontal sinuses. It can be performed as a balloon-only procedure unaccompanied by endoscopic sinus surgery (ESS) in which the sinus ostia are dilated without any removal of bone or redundant mucosa. It can also be combined with ESS, termed a hybrid procedure, in which ESS is performed with traditional techniques and balloon dilatation is used as a complementary procedure in various sinuses as needed.
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The basic technique of balloon sinus dilatation involves advancing a balloon catheter over a guidewire through the natural opening of the sinus. The balloons are available in various lengths and widths that have been designed for specific sinus anatomy. A guide catheter is often used that helps direct the guidewire toward the sinus ostium. When positioned, the balloon is inflated with water under pressure. The balloon is then deflated and removed.
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Currently, balloon sinus dilatation is not applied to the ethmoid sinuses. The ethmoid sinuses have multiple septations, with individual ostia that feed into a larger and variable outflow system. There is no one ethmoid sinus ostium that can be dilated with the balloon. Because of this, balloon dilatation is not a treatment modality that directly addresses ethmoid sinus disease.
Preoperative Considerations
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Determining the applicability of balloon sinus dilatation in the setting of chronic inflammatory disease has been a source of significant contention within the rhinologic community. When balloon sinus dilatation is used in isolation, no bone is removed. Rather, the natural ostium is widened. Surgical objectives of ESS include the restoration of functional mucus flow and air exchange of the sinuses and facilitation of access for topical and irrigated medical treatments. A prevailing principle in ESS is that the bony septations of the sinuses are involved in the chronic inflammatory process and must be removed for the disease process to be adequately impacted. In ESS, the uncinate process is consistently resected, as are the bony septations of the ethmoid sinuses. Balloon sinus dilatation used without traditional ESS techniques does not directly address mucosal and bone inflammation, which is often thought to be a source of continued sinus inflammation.
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For the foregoing reasons, consideration should be given to the severity of the disease present and the extent of surgery necessary to achieve clinical improvement. For balloon sinus dilatation to be performed, the natural ostium must be identified and cannulated. Significant mucosal inflammation may prevent introduction of the guidewire and may be more appropriately treated with a hybrid procedure or ESS without dilatation. Furthermore, bony obstructions and changes caused by osteitis may be present that inhibit the easy placement of the balloon system.
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Patients with nasal polyposis are poor candidates for balloon sinus dilatation without traditional ESS. Nasal polyps may significantly obstruct the natural outflow tracts, and without débridement of the polyps, sinus dilatation is unlikely to adequately address the obstructive aspects of nasal polyps.
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Various anatomic deformities may make balloon dilatation difficult. A deviated nasal septum may make it hard to maneuver the necessary instruments through the nose. Large inferior turbinates or a concha bullosa may also cause difficulty in passing the balloon. Furthermore, a tortuous or complex frontal sinus outflow tract may not allow for easy maneuverability of the guide catheter.
Radiographic Considerations
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Identify the uncinate process and its relation to the orbit and skull base on CT scan. Examine the borders of the frontal outflow tract and, if possible, attempt to determine the location of the frontal recess in three dimensions. Identify significant variations in anatomy that may complicate the ability to pass the balloon, such as a deviated nasal septum, concha bullosa, large ethmoid bulla, agger nasi cell, suprabullar ethmoid cells, complex frontal sinus anatomy, severe inferior turbinate hypertrophy, and nasal polyposis.
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Rule out variants of sinus anatomy that could predispose patients to complications from balloon dilatation. Examples are a dehiscent carotid artery and optic nerve within the sphenoid sinus, herniation of orbital fat into the maxillary sinus or ethmoid complex as a result of prior trauma, the presence of a supraorbital ethmoid cell, or any dehiscence of the skull base.
Instrumentation
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Guidewire: A flexible guidewire is used to determine the location of the sinus ostia. When the technology was originally introduced, fluoroscopy was necessary to confirm placement of the wire within the desired sinus. Now, both flexible and fixed angle guidewires are available with a fiberoptic core that allows the tip to be illuminated. This permits transillumination of the frontal or maxillary sinus to confirm guidewire placement ( Fig. 13.1 ).
Fig. 13.1
Photograph of an illuminated guidewire.
Courtesy Acclarent Inc., Menlo Park, California. Reproduced with permission.
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Guide catheter: The guide catheter is a hollow-bore tube through which the balloon catheter and guidewire are passed. The tip of the catheter is configured at various angles depending on the sinus to be dilated. The purpose of the guide catheter is to make it easy to advance the balloon through the nasal cavity and direct the balloon into the sinus. Newer catheters have been developed that allow for suction to aid in visualization. Another recent innovation is image guidance localized balloons that allow for computed tomographic (CT) image guidance confirmation of sinus anatomy and balloon positioning ( Fig. 13.2 ).
Fig. 13.2
Photograph of image-guided balloons.
©2017 Medtronic. All rights reserved. Used with the permission of Medtronic.
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Balloon: Balloons are available in various diameters and widths. Depending on the sinus to be dilated, a surgeon may choose a wider and longer, or narrower and shorter balloon. Balloons are passed over the flexible guidewire and through a catheter to be introduced into the sinus ( Fig. 13.3 ). Other devices have been designed that combine the balloon and guide catheter into one system ( Fig. 13.4 ).
Fig. 13.3
Photograph of balloon dilators.
Courtesy Acclarent Inc., Menlo Park, California. Reproduced with permission.
