Balloon Sinuplasty: A Valuable Tool in the ENT Toolbox

[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.

[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.