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Balloon Sinuplasty: A Valuable Tool in the ENT Toolbox

Author Julia Casazza covers Balloon Sinuplasty: A Valuable Tool in the ENT Toolbox on BackTable ENT

Julia Casazza • Feb 12, 2024 • 38 hits

Balloon sinuplasty improves sinus drainage by using a wire-guided inflatable balloon to enlarge the ostia. In the right patient, the procedure can augment the efficacy of sinus rinses without requiring general anesthesia as a traditional functional endoscopic sinus surgery (FESS) does. Dr. Ayesha Khalid, a rhinologist with Cambridge Health Alliance, recently sat down with BackTable ENT to speak about how she determines patient candidacy for balloon sinuplasty and how she counsels patients on the procedure.

This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable ENT Brief

• During balloon sinuplasty, the otolaryngologist inserts and then inflates a wire-guided balloon to enlarge the sinus ostia. Balloon sinuplasty can be performed in both OR and office-based settings.

• Balloon sinuplasty is an effective adjunct to medical therapy and functional endoscopic sinus surgery (FESS), according to Dr. Khalid.

• Balloon sinuplasty can be used in both primary and revision sinus cases.

• Patients with stereotypical sinus pain and scattered sinus disease seen on CT are ideal candidates for balloon sinuplasty. Extensive polyposis, severe nasal septal deviation, or chronic osteitis are contraindications to the procedure.

• Sinus barotrauma patients whose symptoms don’t improve after a two-month regimen of saline rinses and a two-week concurrent course of antibiotics can benefit from a balloon sinuplasty to maximize frontal sinus drainage.

Balloon Sinuplasty: A Valuable Tool in the ENT Toolbox

Table of Contents

(1) Applications of Balloon Sinuplasty

(2) Identifying the Right Patient for Balloon Sinuplasty

(3)
Balloon Sinuplasty for Patients with Sinus Barotrauma

Applications of Balloon Sinuplasty

Alongside medical therapy and endoscopic sinus surgery, balloon sinuplasty is a valuable tool for the management of sinus disease. Balloon sinuplasty allows the otolaryngologist to optimize sinus drainage in a minimally invasive, office-based manner. Balloon sinuplasty is used in both primary and revision contexts. In particular, sinus barotrauma patients who fail medical management often benefit from a frontal balloon. In patients with obstructive scarring following FESS, balloon sinuplasty can enlarge the ostia of an affected sinus in-office.

[Dr. Gopi Shah]
Tell me about those patients, the variety of the sinus patients. Are we talking, mostly chronic sinusitis? Is there ever a role in acute barotrauma? Let's go into who you feel like the indication.

[Dr. Ayesha Khalid]
Usually, the way I approach the rhinology patient, whether it's recurrent acute sinusitis, chronic sinusitis with polyps, or sometimes patients have an incidental and very specific problem. For example, I get acute frontal sinusitis whenever I fly for work, and it acts up, and the pressure doesn't allow me to take trips.

In a patient like that, I would do a very limited procedure in the office and do a frontal sinus balloon because they've been on treatment and they failed. Versus maybe the other extreme, which is chronic sinus patients with or without polyposis, even ones that I've operated on before.

I may do a revision balloon to reopen up a frontal sinus or maxillary sinus that has been scarred and then really think about getting the drug topical therapies in a better position for them. I don't really have a specific patient that I use balloons for, but I think about it a lot in terms of one of the tools that I use, whether it's in the operating room or the office.

[Dr. Gopi Shah]
For the patients that have chronic sinusitis with polyps, are those the patients that maybe the polyp burden has decreased, you've done a FESS on, but maybe the isolated frontal or sphenoid, when they come in, look small?

Tell me a little bit about the chronic sinusitis with polyp patients. I only ask because most of the time we think of FESS and microdebriders and making antrostomies big for those patients for the same reasons of topical irrigations and topical steroids and things like that.

[Dr. Ayesha Khalid]
No, I think that's exactly as you stated. A chronic sinusitis patient with polyps, my first goal is how can I do an endoscopic sinus surgery generally in the operating room, unless they have comorbidities, and get enough of an antrostomy that the topical therapies will get through.

I will say, over the years, the size, for example, of my maxillary antrostomy, even using instruments, has really gotten smaller. I'm trying to keep the natural milieu of the nose and I'm learning that inflammation is definitely the problem.

Then in those patients, whether they had surgery with me or someone else, the polyp burden may have gotten smaller, but they, for example, really have some polypoid inflammation or polyps in the superior recess.

Do I take these patients that have scarred off their frontal sinus or their frontal recess back to the operating room? Or can I manage them in the office, for example, with a frontal sinus balloon, perhaps even drug-eluting therapies or a stent or a spacer?

I will often resort to that. That revision sphenoid and frontal, in fact, is exactly the way that I use balloon sinuplasty for revision cases.

Listen to the Full Podcast

Balloon Sinuplasty: Evolution, Efficacy & Expert Insights with Dr. Ayesha Khalid on the BackTable ENT Podcast)
Ep 137 Balloon Sinuplasty: Evolution, Efficacy & Expert Insights with Dr. Ayesha Khalid
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Identifying the Right Patient for Balloon Sinuplasty

Patient anatomy and pathology determine whether balloon sinuplasty is an appropriate intervention. When reading CT scans, assess for severe septal deviation and chronic osteitis. Either finding will impede balloon access to affected sinuses; in these cases, traditional FESS with septoplasty is a more appropriate option. Patients with stereotypical facial pain, scattered sinus disease, or those with neither of these findings are excellent candidates for balloon sinuplasty. Patients with polypoid pathologies (e.g. cystic fibrosis and allergic fungal sinusitis) will require more traditional FESS. Depending on disease extent, a hybrid FESS-balloon approach can minimize the use of instrumentation (and thus scarring).

[Dr. Gopi Shah]
Are there certain pathologies that you're like, I'm going to have to use instrumentation on this? Are there certain that just pop up where you're like, we got to open this up? I think of allergic fungal sinusitis and I'm like, that's got to be opened up. I think of like maybe, what about your CF patients or your PCD patients? How do you think about those groups of patients?

[Dr. Ayesha Khalid]
I think that's absolutely true. There's certainly populations, CF, all the ones that you named that then also lead to polyposis. You endoscopically, preoperatively, see polyposis and you may not see the inverting papilloma that lays behind the allergic fungal that sits in the maxillary sinus, the cystic fibrosis patient. Those patients, I think, deserve, and usually in my hands, will get a traditional instrumentation endoscopic sinus surgery of all the sinuses or all the sinuses that are affected. For example, with the allergic fungal, it can often be unilateral on the scan.

Following that, the question becomes, in revisions that occur as these diseases often lead to recurrence of the inflammation of the polyps, I'm really looking for ways to minimize their further surgeries as polyps come back or disease comes back.

[Dr. Gopi Shah]
Are there certain symptoms that tend to get better with balloon sinuplasty or when those symptoms come up, that's going to be on your, as an option for you?

[Dr. Ayesha Khalid]
I think the number one symptom you touched upon, facial pain, particularly asking the patient to point.

Many people will say, "My face hurts" or "My head hurts," but if they're pointing directly to a cheek sinus, they're pointing to their forehead, or sphenoid patients who are sometimes tricky and can on imaging then have isolated sphenoid disease will often point to the top of their head or say that it pushes down.

That's generally number one to make me think of balloon sinuplasty as an option, especially if on their imaging they have scattered disease or particular sinuses that are involved. Then I say balloon sinuplasty can address this and I don't need to go to instrumentation.

The second thing I've noticed over the years, which is very interesting, and I think has been a hot topic of debate within rhinology and the world of ENT, is nasal congestion. Or patients describing it as, "I feel clogged or stuffy," particularly where glasses rests, that mid ethmoid region.

I will so often have done a frontal balloon sinuplasty, either as part of a procedure or in the office in isolation. The patients will say, "My forehead pressure or my headaches are much, much better. By the way, I feel I get more air or I can breathe better." That is very anecdotal, in my experience, but has been super interesting when I think about laminar airflow in the nose.


Balloon Sinuplasty for Patients with Sinus Barotrauma

In cases of sinus barotrauma, abrupt changes in atmospheric pressure injure mucosa, predisposing patients to subsequent infection and inflammation. Patients typically report recent air travel (as in the case of pilots, flight attendants, and consultants) or scuba diving. Dr. Khalid places her barotrauma patients on saline/budesonide sinus rinses and asks them to complete a two-week course of antibiotics. If their symptoms don’t ameliorate after two months of medical management, she recommends balloon sinuplasty, intending to increase responsiveness to medical therapies.

[Dr. Gopi Shah]
In terms of the barotrauma patients, how much time do you give them after, let's say, you have a patient had a flight or maybe it's a stewardess, somebody that actually this is their profession and they complain of right frontal headache or maybe it's left face pain or something? How much time do you give them to say, hey, let's see if this gets better, try some decongestants, saline, whatever? How much time do you give them and what's your medical management? Then when do you consider a balloon for those patients?

[Dr. Ayesha Khalid]
I actually have a few airline stewardesses and pilots. That is the perfect question as well. As consultants. That is a field where they often travel every Monday and Thursday.

If I see a patient for the first time, whether it's barotrauma or even chronic sinusitis or recurrent acute, I would say generally I'm trying medical therapy for two months. Unless they've been referred from another ENT or one of my colleagues and have already had a few months of medical therapy.

For me, a mainstay of medical therapy always includes a saline rinse. It generally includes some form of topical steroids. I have often done the budesonide solution within the saline or every patient, to be honest, has been on a fluticasone, Flonase, or Rhinocort spray.

That said, I have them do it all at once. I say, "I would like you to use a saline rinse. I would like you to have a short course of antibiotics if you have not in the last few months." For me, that's two weeks. It has evolved from three weeks to two weeks in the last many years.

The time for me to see the patient back to allow them to decide to move forward on their own with surgical intervention has shrank from three to four months down to two, sometimes even six weeks. I would say the third biggest change in my practice over the last few years is I don’t often get repeat CTs.

Podcast Contributors

Dr. Ayesha Khalid discusses Balloon Sinuplasty: Evolution, Efficacy & Expert Insights on the BackTable 137 Podcast

Dr. Ayesha Khalid

Dr. Ayesha Khalid is the chief of the ENT division at Cambridge Health Alliance in Massachusetts.

Dr. Gopi Shah discusses Balloon Sinuplasty: Evolution, Efficacy & Expert Insights on the BackTable 137 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2023, October 24). Ep. 137 – Balloon Sinuplasty: Evolution, Efficacy & Expert Insights [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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