Christopher T. Melroy, MD, FARS
Over the last several decades, there have been many changes in technology that have improved our lives. Rhinology, or the sub-specialty of ENT that deals with nasal and sinus disease, has dramatically benefited from these advances. In the mid 1980s, small telescopes called endoscopes allowed surgeons to visualize the inside of the nasal and sinus passages and revolutionized nasal and sinus surgery. These advances continue as technology allows Rhinologists to do more, to be more accurate, to be less traumatic, and to be more precise. Once such advancement was the development of the balloon dilating catheter and its adaptation to sinus surgery.
In the 1980s, the field of cardiology drastically changed with the use of angioplasty. This well-known procedure uses a balloon dilating catheter to open up diseased and blocked blood vessels around the heart. This was the first surgery of its kind that could treat this type of heart disease in a minimally invasive fashion. Millions of patients have benefited from this technology and had had their heart disease managed without "open heart surgery."
This technology has been adapted into the field of Rhinology and Sinus Surgery. Long before the balloon was used in the nose and sinuses, the concept of "functional endoscopic sinus surgery” ( commonly known as FESS) was introduced. It is based upon the principle that surgeons can restore the natural drainage pathway of the sinuses by relieving obstruction or blockages that contribute to the disease process. This is commonly done in a conservative fashion in order to preserve the function of the sinuses without damaging natural structures. In general, standard instrumentation is used to remove tissue (including bone and its surrounding mucous membrane or “pink lining”) from the area of the natural openings of the sinuses. Doing this helps to treat disease and to restore the sinuses’ normal drainage pathways.
Balloon Catherters in sinus surgery
In 2005, a company known as Acclarent (California, USA) released a commercially available product that was the first to use balloon dilating catheter technology to treat sinus disease. Overall, the concept is simple. A guidewire is passed from the nasal cavity into the peripheral sinus (the frontal, maxillary, or sphenoid sinus). Once it has been confirmed that the guidewire is in the sinus, a balloon dilating catheter is passed over this wire to the narrowest part of the sinus drainage pathway. This high pressure balloon is briefly inflated, and the pressure of the balloon widens the outflow tract of the sinus by fracturing bone and moving it along with its mucous membrane. The final result is a dilated or widened outflow tract from the sinus that can be done without actual tissue removal.
Although this technology initially was met with criticism, clinical studies have demonstrated that it is a safe and effective tool in the management of chronic sinusitis. The American Rhinologic Society as well as the American Academy of Otolaryngology-Head and Neck Surgery both currently have favorable position statements concerning this technology. These devices are FDA approved and have been used on tens of thousands of patients.
To simplify things, the balloon dilating catheter can be used in 2 ways. One way is just like any other instrument or tool used during functional endoscopic sinus surgery- it is used as a minimally invasive tool during a procedure where tissue is actually removed. Another way that it can be used is as a stand-alone procedure, that is when only the balloon and no other instrumentation is used to open a sinus. The description of this technique was initially trademarked by Acclarent and is known as “balloon sinuplasty”TM. With this technique, no tissue is actually removed from the level of the sinus opening. It has been shown that use of minimally-invasive instruments may result in less postoperative pain, less postoperative pain medication use, and a quicker recovery. It cannot be used in all situations, and it cannot be used in all sinuses. It is one of a vast armamentarium of instruments that a surgeon may choose from in different surgical situations.
Even over the last several years, there have been advances in balloon technology. Initially, to confirm that a surgeon was in a sinus, an x-ray machine had to be used during surgery to confirm correct placement of the guidewire. This exposed patients to intraoperative radiation that they would not otherwise get with standard instrumentation. Now, sinus access can be confirmed with a lighted guidewire- one with a bright fiberoptic light at the end of the flexible guidewire. A surgeon can confirm proper placement of this within a sinus as he or she can see the bright light from the tip of the flexible guidewire shining through the skin. Other peripheral products such as irrigation catheters and stents have also been developed. Other companies have also released products (Entellus Medical, Minnesota) allowing balloon dilation of sinus openings in a slightly modified fashion.
Regardless of the name of the procedure, the instrument, or the technique, this is sinus surgery. The indications are no different than the indications for standard endoscopic sinus surgery or FESS. The most common application of this is for chronic sinusitis that has not been able to be controlled after a long duration of medical management that includes long courses of antibiotics. The balloon dilating catheter is a tool to be used in endoscopic sinus surgery. It is the adaptation or application of minimally-invasive balloon technology to the field of sinus surgery. All procedures have potential risks and complications, and for a full discussion of all of these issues, please contact your physician.