How to Perform Balloon Sinuplasty in the Office Setting

[Dr. Gopi Shah]
Say you're taking a patient to do a frontal balloon sinuplasty in the office. What's your setup like? How do you like to anesthetize and control for bleeding in the office?

[Dr. Ayesha Khalid]
Similar to the office and the operating room, I have a very similar protocol in both. The difference, of course, being that in the office, I give a lot more time to putting topical pledgets that have a lidocaine with Afrin solution that they're soaked in. We used to use cotton balls and the aerosolizing spray.

To be honest, during COVID, when I wasn't allowed at our hospital to use the aerosolizing spray, I switched to the long cottonoid pledgets that we would normally use in the operating room. I've stuck with those. First step is five to 10 minutes of putting the pledgets in right in the front.

Second step is another 5 to 10 minutes, closer to 10, where you put one in the middle meatus on both sides, one inferior. By the time you get to step three, you're 15 to 20 minutes in and I'm doing an injection with the lidocaine with epinephrine now. I am finding that they should not feel their injection.

[Dr. Gopi Shah]
In terms of your post-op management after the balloon or the hybrid balloon cases, rinses, what else? More rinses?

[Dr. Ayesha Khalid]
My staff laughs that you can come to see me for literally any problem in otolaryngology and you might leave with a saline rinse so you breathe better. That being said, I don't generally use very much packing. If I use packing, it's just dissolvable packing as a middle needle spacer. Rinses are key, avoidance of nose blowing is key. Antibiotics, generally, are for, depending on the patient, three or four days if I was continuing it from a seven-day total for a recurrent acute or minor sinusitis. Nasal polyposis, they'll continue antibiotics and prednisone for a week after surgery at much lower doses, honestly, than I used to use in the past.

[Dr. Gopi Shah]
In terms of post-op, do them back in clinic at like a week, two weeks, four weeks?

[Dr. Ayesha Khalid]
That has evolved. I used to see every patient at a week, then I got bolder, moved it out to two weeks, three weeks. Honestly, I'm now back at a week. I'm at a week and a month. I'll see them at about a week, 7 to 10 days, three to four weeks, and then two or three months out. That's generally the norm. One of the reasons is because in this era of healthcare, it's less to do with how their nose looks and more to do with planning on getting back to work.

Many of them want to go back to work and I want to see them prior. If they do construction, plumbing, house cleaning, a lot of things where they're exposed to different dust and situations. I use the 7 to 10 day not just because it's when I want to do the endoscopy, but mostly because it gives me a chance to chat with the patient about the next couple of months and what happened in their surgery.

[Dr. Gopi Shah]
In terms of post-op, like repeat CT scans, what are the indications in your practice to re-image a patient?

[Dr. Ayesha Khalid]
I try as much as possible to not re-image the patient. It will only lead to grief for yourself as a surgeon. However, when asked, when patients say, "I'm breathing great out of one side but the other--" let's say, "The left side is still bothering me," I will never generally reimage unless a few months have gone by. I'd like to say six, maybe even a year. Some patients, rightfully, they're starting to get polyps, I'm concerned about a particular sinus. It is not common practice for me. I would say 95% of my patients never get reimaged. If they do get reimaged, it's because I, like them, are concerned that they need a revision of some sort.