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BackTable / ENT / Article
How to Perform Balloon Sinuplasty in the Office Setting
Julia Casazza • Updated Feb 12, 2024 • 34 hits
Balloon sinuplasty can provide lasting relief to sinusitis patients. It is most appropriate for uncomplicated revision sinus cases or patients with scattered disease and no polyps. Keeping in mind patient comfort and materials available, this procedure can safely be performed in-office, obviating the need for general anesthesia. Dr. Ayesha Khalid, a rhinologist with Cambridge Health Alliance, recently sat down with BackTable ENT to share the details of how she performs this common procedure in the office setting.
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
• Adequate anesthetization and decongestion are key to patient comfort during in-office balloon sinuplasty. Plan to leave oxymetazoline/lidocaine-soaked pledgets in the nose for at least twenty minutes.
• Pre-treatment with three days’ worth of antibiotics can eliminate the need for sinus irrigation following balloon sinuplasty.
• While sinus balloons come equipped with lighted guide wires, trainees may find it helpful to use image guidance while performing the procedure.
• Around 70% of balloon sinuplasty patients have lasting relief from their procedure. The odds of success are lower in patients with a greater polyp burden.
Table of Contents
(1) Preparing for a Smooth In-Office Balloon Sinuplasty Procedure
(2) Balloon Sinuplasty Procedure Technique
(3) Management Following Balloon Sinuplasty
Preparing for a Smooth In-Office Balloon Sinuplasty Procedure
Successful in-office balloon sinuplasty requires the organization of procedural materials and space. Relative to an OR procedure, Dr. Khalid spends more time anesthetizing and decongesting an awake patient. She soaks pledgets in a 50-50 mix of oxymetazoline-4% lidocaine, then leaves them in the nose for twenty minutes before injecting the operative field with a mixture of lidocaine and epinephrine. She plays music in her office and instructs any trainees working with her to avoid commenting on the procedure to help keep the patient calm.
[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.
Listen to the Full Podcast
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Balloon Sinuplasty Procedure Technique
Dr. Khalid tailors her approach to balloon sinuplasty to maximize patient comfort. She instructs patients to take three days’ worth of antibiotics and oral steroids prior to their sinuplasty to decrease the risk of purulence. She inserts the balloon under endoscopic guidance with a zero-degree scope, dilates the sinus twice, and then withdraws it. If dilating the maxillary sinus, uncinectomy may be necessary for access, Because patients are pre-treated with antibiotics and instructed to use sinus rinses routinely, she does not irrigate the sinuses afterward.
[Dr. Gopi Shah]
In terms of ballooning, do you dilate the sinus once, twice? How? I guess maybe it depends on the system for how many atmospheres you do it for and how long. Or tell me about those details.
[Dr. Ayesha Khalid]
That's funny that you ask. I always dilate twice. I can't tell you why because sometimes I dilate once and I clearly see the frontal recess open and yet it it must be my training or a force of habit.
I generally, for example, for the frontal or the maxillary, once I know and I've used in the office, a lighted guide wire and I have confirmation, I do it once. I withdraw and I do it again. It's always twice…
[Dr. Gopi Shah]
Then you make an interesting point about the max. Do you ever have to take the uncinate down to get in to the max?
[Dr. Ayesha Khalid]
The maxillary sinus involves strategic angles, prayer, self-affirmations in your head if you're in the office. Yes, you do. One of the things I forgot to mention that I always open on the back table is like a ball tip probe. I have a tool that has a freer on one side and a little curved probe on the other. I may have to anteriorly just pull gently the uncinate process, tug it forward to allow the maxillary balloon to go in. Now, I'm very tentative in terms of how much I do to the uncinate. I think if I was in a private practice setup, and I had my own staff that I would train, I would probably do much more of an ambitious uncinectomy if needed to get in. In my hands, I will freely admit sometimes I will get through the turbinate reduction, and I shave the turbinates in the office. I'll get through the frontal, I'll get through the sphenoid, I'll get through one max, and I just can't get into the other one. It does happen.
In that case, if you're well set up for, really, just taking down some of the uncinate, I would do it. I wouldn't do it in our hospital just because of resources, timing, and setup, but that’s something I’m looking to do in the future.
Management Following Balloon Sinuplasty
Post-procedural management following balloon sinuplasty includes saline sinus rinses for all patients and a week of antibiotics plus prednisone for those with nasal polyposis. Dr. Khalid re-evaluates patients at one week, one month, and three months post-procedure. She does not obtain repeat imaging unless she suspects a revision procedure will be necessary. Of balloon sinuplasty patients, 70% experience enough relief so that further procedures are not needed.
[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.
Podcast Contributors
Dr. Ayesha Khalid
Dr. Ayesha Khalid is the chief of the ENT division at Cambridge Health Alliance in Massachusetts.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
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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