Endoscopic view of balloon catheter dilation of sinus ostia (balloon sinuplasty).

Techniques to improve sinus drainage and ventilation have been developed over hundreds of years. The first modern-day procedures were still relatively crude; for example, Cowper developed a procedure to drain the maxillary sinus by removing a carious tooth from the maxilla. (1) Later, inferior and middle meatal antrostomies became popular, and the merits of each were debated for many years. (2,3) Next, functional endoscopic sinus surgery (FESS) was developed and refined in Austria by Messerklinger, Stammberger, and Wolf. (4,5) Kennedy recognized that FESS is an important way to achieve sinus drainage and ventilation when he introduced the technique in the United States. (6) FESS became and remains the gold standard for sinus surgery today, regardless of whether conventional or powered instruments are used.

There are times when a surgeon encounters a patient who would benefit from a slightly larger sinus ostium. This is particularly true with regard to the frontal recess and frontal sinus, where aggressive surgery is not indicated or advisable. Similar situations sometimes apply to the sphenoid sinus ostium and occasionally to the maxillary sinus ostium.

A new, minimally invasive technique--balloon catheter dilation of paranasal sinus ostia (balloon sinuplasty)--has been described by Brown and Bolger. (7) Their premise is that a stenotic sinus ostium can be enlarged by the pressure applied by a small balloon catheter. The feasibility and safety of this procedure have been evaluated by Bolger and Vaughan. (8)

The procedure begins with the application of a vasoconstrictor such as 1:1,000 topical epinephrine on a cotton pledget followed by an injection of 1% lidocaine with epinephrine in the area to be dilated. A hollow, plastic sinus guide cannula is placed near the entrance of the involved sinus under endoscopic visualization, usually with a 0[degrees] or 30[degrees] telescope (figure, B). With the aid of a fluoroscopic C-arm (figure, C), a sinus guide wire is inserted through the sinus guide cannula into the sinus ostium (figure, D and E). A catheter with an attached balloon is fed over the sinus guide wire through the sinus guide cannula and into the sinus. On the fluoroscopic image, the proximal and distal limits of the balloon are visible as black, radiopaque dots (figure, F and G). These markers are used to correctly place the sinus balloon catheter in the sinus ostium, with the distal mark placed inside the sinus and the proximal mark external to the sinus ostium (figure, F and G).

[FIGURES A-G OMITTED]

After the balloon has been accurately placed, an assistant inflates it to 6 to 10 atmospheres while the surgeon holds the sinus guide cannula, sinus guide wire, and balloon catheter in place. A radiopaque fluid is used to inflate the balloon, making it easily visible on fluoroscopy as it expands 5 to 7 mm, depending on the size of the balloon used (figure, G). The balloon is left inflated for several seconds and deflated; it can be moved slightly and reinflated if necessary, particularly in the frontal recess. The involved sinus can be lavaged if necessary; the same guide wire can be used to direct a lavage catheter device into the involved sinus. During dilation, the proximal end of the balloon external to the sinus entrance can also be visualized through the endoscope (figure, H). After the balloon has been deflated and removed, the endoscope is used to inspect the frontal recess or sinus ostium (figure, I).

[FIGURES H-I OMITTED]

Sinus ostia balloon dilation is a useful new option, but we need a long-term study to give us a better understanding of the indications for its use and the potential complications of this procedure. The important issue that needs to be studied is long-term patency.

References

(1.) Loeb HW. Operative Surgery of the Nose, Throat, and Ear for Laryngologists, Rhinologists, Otologists, and Surgeons. St. Louis: Mosby: 1917.

(2.) Lund VJ. Inferior meatal antrostomy. Fundamental considerations of design and function. J Laryngol Otol Suppl 1988:15:1-18.

(3.) Hilding AC. Experimental sinus surgery: Effects of operation windows on normal sinuses. Ann Otol Rhinol Laryngol 1941:50: 379-92.

(4.) Messerklinger W. Endoscopy of the Nose. Baltimore: Urban & Schwarzenberg; 1978.

(5.) Stammberger HR. Functional Endoscopic Sinus Surgery. Philadelphia: B.C. Decker: 1991.

(6.) Kennedy DW. Functional endoscopic sinus surgery. Technique. Arch Otolaryngol 1985; 111:643-9.

(7.) Brown CL, Bolger WE. Safety and feasibility of balloon catheter dilation of paranasal sinus ostia: A preliminary investigation. Ann Otol Rhinol Laryngol 2006:115:293-9.

(8.) Bolger WE, Vaughan WC. Catheter-based dilation of the sinus ostia: Initial safety and feasibility analysis in a cadaver model. Am J Rhinol 2006;20:290-4.

Dewey A. Christmas, MD; Joseph P. Mirante, MD; Eiji Yanagisawa, MD

From the Department of Otolaryngology, University of South Florida College of Medicine, Tampa, and the Halifax Medical Center, Daytona Beach. Fla. (Dr. Christmas and Dr. Mirante); and the Southern New England Ear, Nose, Throat, and Facial Plastic Surgery Group; the Section of Otolaryngology, Hospital of St. Raphael; and the Section of Otolaryngology, Yale University School of Medicine, New Haven, Conn. (Dr. Yanagisawa).