Podcast Transcript: Balloon Sinuplasty: Evolution, Efficacy & Expert Insights

[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.

I don't inflate and then wait a certain period of time. This is not, as I'm training people, the same as the Eustachian tube balloon, I dilate and then I tell them, go ahead and deflate.

What's interesting is, sometimes the assistants feel like they have to hold it there for a little while. There is a little bit of who you're working with and letting them know that you don't need to wait once you've dilated. You can go ahead and deflate it after a few seconds.

[Dr. Gopi Shah]
Is there a certain pressure or is it going to be system-dependent of how many atmospheres you're going to dilate?

[Dr. Ayesha Khalid]
It is system-dependent. I think that the key-- Now, you bring up another great question, which is the practicing of the inflation and dilation, deflation of the balloon, I always have whoever's assisting me practice it on the back table first. I forgot to mention that.

The last thing you want is the syringe doesn't attach or you want to irrigate the maxillary sinus after you've dilated it. You want to do all those maneuvers and show them, here, push it all the way down. That's a full inflation. Make sure you're using saline. Let go. All those things. I think I do those all on the back table every time, even with the same assistant.

[Dr. Gopi Shah]
If you've dilated it on the back table when you deflate it and want to use it to then insert into the sinus, does that change the shape or make it too hard then to get it into the sinus? Once it's already been inflated and deflated, does that make it harder or more difficult to pass into the sinus?

[Dr. Ayesha Khalid]
No. I've never found that to be the case. I think unlike some of our other tools that we use within ENT, it doesn't change the architecture. One other little tip or trick is to pull the-- Personally, I use the Entellus balloons. I've used all of the different balloon types in the past.

Now that Stryker has Entellus, it allows me to have the RAN needle, it allows me to have the balloon. One tip on the Stryker balloon, I should say, is I do ask the assistant, practice, make sure you can inflate and deflate.

When you are holding it for me, pull the lighted guide wire back until I'm in the sinus and then forward the guide wire because that will help the lighted guide wire not bounce off the edges and allow you to get into the Ostia much more easily.

[Dr. Gopi Shah]
Entellus or the Stryker balloon, so the Express balloon, yes?

[Dr. Ayesha Khalid]
Yes.

[Dr. Gopi Shah]
Okay. It's now rebranded as the Express Balloon. It's light-guided. Is it also image-guided as well?

[Dr. Ayesha Khalid]
You can use it with image guidance, which I was saying earlier, that's another aspirational sign that I'm not lucky enough to have image guidance.

When folks tell me about some of the pathology that would make them nervous about using a balloon sinuplasty, particularly in a patient, whether it's in the operating room, but particularly in the office, if you have a recurrence of polyposis in the superior meatus and you have scarred the frontal and you want to do a balloon, having the image guidance that then attaches onto the Express to just reaffirm for you beyond the lighted guide wire, you're in the right place, that's amazing.

I don't have that. I count on the lighted guide wire, and I will say I count on tactile feel. If your frontal sinus is completely opacified, sometimes it doesn't light up. I feel that when it goes in easily and there's no pushing and I know I'm in the right place, I'll still inflate. I think if people are starting out, using those two together is amazing for giving you reassurance.

[Dr. Gopi Shah]
Are there certain sizes of the balloons or angles that are specific for the different sinuses? I assume that there's probably a 70-degree, a 90 for frontal and max. Is it pretty standard in terms of angles and sizes?

[Dr. Ayesha Khalid]
It's actually become so easy in that I feel that perhaps they designed the Express with my order in mind because it comes ready to do the frontal. The same balloon comes and it's pre-angled and looks very much, to me, like a frontal sinus ostium seeker with that same upward angle.

Then it has a little plastic piece that you can re-change that's marked. I think S and M, I believe, are the markings. I could be mistaken because my assistants always do this. You can then edit it from the frontal into a maxillary, into a sphenoid.

If you remember what I said earlier, the frontal and the sphenoid, fairly standard, easy to do, I always find they go in. Maxillary, it's not the angle is the issue. It's the arm of the balloon that's pushing against your middle turbinate and your septum and the patient might feel pressure if you are doing it in office. You may have to move that angle between 120 and 130 to get it in.

It's fairly standard and well-marked. If you're doing it yourself and you have someone, a helping hand, even an MA, a nurse, a PA, a resident, you can just tell them, look at the letters on the plastic and curve it to that.

[Dr. Gopi Shah]
It's the same balloon. I can open just one balloon for all the sinuses on both sides. It's not like I have to open up separates because I can adjust it.

[Dr. Ayesha Khalid]
Yes.

[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.

[Dr. Gopi Shah]
In terms of getting into the max and the frontal, what angled scope or-- Do you use just the standard zero or do you like an angled scope for those cases?

[Dr. Ayesha Khalid]
Again, it's interesting. I haven't thought about this in a while, but when I started practice post-fellowship I used a 0, 30, 45-degree, and 70 all the time. The 45 very often. I will say that I hardly ever use a 70-degree scope and 90% of my cases, particularly if I'm doing balloons, is with a zero degree. At the most, I'll use a 30-degree. The 30-degree will often be for confirmation. Whether I'm looking up or whether I'm looking at the maxillary.

[Dr. Gopi Shah]
In terms of the max, do you ever have like-- We get problems with recirculation even with open-- Not open, but, formal maxillary antrostomies. How often do that with a balloon sinuplasty?

[Dr. Ayesha Khalid]
Very rarely. I will see that I will go in to do a balloon sinuplasty for the first time, for example, and I'll notice an accessory os or some recirculation, and I'll think to myself, "Oh, perhaps I need to balloon this patient, and I need to connect those two." To be honest, most of the recirculation for me following a maxillary antrostomy has been after my own surgery with instrumentation. Which is part of why I have become of a smaller maxillary antrostomy even with instrumentation than I used to be if you looked at my surgeries many years ago.

[Dr. Gopi Shah]
Yes. It's funny, in training, we don't see our post-ops and then we get out, we're like, Oh, God." Yes. In terms of culture and irrigation, when you do a balloon dilation, is that a normal part of your routine? Do you do it for every case or only if you're getting drainage out of the sinus?

[Dr. Ayesha Khalid]
I don't generally and have never been. Perhaps it was part of my training, but on an initial surgery, barring allergic fungal sinusitis, odd findings, maybe a post-dental infection which, actually, sometimes is the reason I'm doing a maxillary balloon or a maxillary antrostomy, in those patients, I'll culture. Otherwise, I really don't culture patients at all. That's not part of my culture-directed antibiotics that I used to do very much in training and post-residency a little bit post-fellowship.

I instead utilize the fact that movement of the cilia and the sinuses with irrigation is really the key. To the first question, culture is never a part of my routine. In fact, I get extremely sad when our physician assistants do culture because the patients look at the results and really obsess over the organisms and really don't obsess over the rinsing, which is what you want them to be doing.

For the second part, I only irrigate again if there is frank purulence that I see, but I guess I should preface with I often pre-treat. It used to be when I was in training fellowship for a few years out I would treat patients for seven days prior to surgery with an antibiotic. Especially if they had chronic sinusitis or any purulence or polyps, as well as prednisone.

I have shrank that treatment time down and I'm often down to about three days, but because I have had them on an antibiotic and sometimes on steroid, they usually don't have purulence the day of surgery. If I see it, I will irrigate a particular sinus, but I generally do not irrigate in the office post-balloon. Then in the operating room, of course, we irrigate anyway, so it does its function.

[Dr. Gopi Shah]
With the express balloons you know, do they have like an inner cannula or something that you can irrigate if you want to or if you see something there? Is that part of their system?

[Dr. Ayesha Khalid]
Yes. In fact, I have a case coming up. It's very easy to attach a syringe and be able to irrigate the sinus once you're in. I have a case coming up where I pre-explained to the patient, I will do this procedure for you in office, it will limit your time off, you want a less invasive, but by the way, I see the pus in your maxillary sinus. It may be strange to have the feeling of the irrigation. Some of it may run down the back of your throat, so we will be making that sound with the suction.

If you're going to irrigate, it will be leading to better results often. However, you have to bear in mind that if you're irrigating in office, you want the patient to be comfortable and they often don't like the sensation of choking, so you have to just be very ginger with the suction and make sure you capture it right away.

[Dr. Gopi Shah]
Yes. Just to go back to the patients and what-- Who you can just do a balloon in it makes, I understand, isolated frontal or maxillary, sphenoid. If you do have opacification in the anterior ethmoid or in posterior ethmoid, and let's say this is no polyps, chronic sinusitis, no polyps, for those patients, do you do just balloons? Who are the patients that you decide, no, I need to go and do an anterior ethmoidectomy or I need to go ahead and still do-- Enter the bulla?

[Dr. Ayesha Khalid]
I think a lot of the patients you're describing sound more that I would be in the category of like a hybrid FESS. If I see disease in the posterior ethmoid, that's very concerning and that definitely makes me lean towards I will be doing traditional instrumentation and opening up the maxillary sinus and the ethmoidal bullas and opening up the posterior ethmoids. Perhaps now more than ever and compared to prior.

I’m not necessarily taking down every bony lamellae if I'm not seeing polyps. I will still, in that case, sometimes simply balloon the frontal as a hybrid because most of their issue was in the ethmoids. That's the second category. The first patient you mentioned, scattered anterior ethmoidal disease but no polyposis, perhaps, let's say, some frontal opacification on one side or the other or frontal recessed disease and let's say some maxillary disease, I will still allow those patients, driven by the patients many of the times because I'll give them that offering, to do balloon sinuplasty along with turbinates.

I'll simply lower the percentage. I'll say there's still that chance. 70% you're very happy, you're clear, and you're sick less often, and you're less congested, 30% chance we're doing a bigger procedure down the road, so I still give them the balloon only option.