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Balloon dilation of the sphenoid sinus ostium for recurrent sphenoid sinusitis.

A 45-year-old white woman with a 3-year history of recurrent sphenoid sinusitis presented with complaints of retro-orbital pain predominantly on the left side, as well as occasional vertex headaches. Congestion and intermittent nasal drainage accompanied the sinus infections, which usually responded well to oral antibiotic therapy. She was a nonsmoker and denied allergy problems. Physical examination revealed nasal congestion and inflamed nasal mucosa, but no intranasal polyps.

[FIGURE 1 OMITTED]

Endoscopic examination of the left nasal cavity revealed a copious amount of purulent, white discharge draining from the left sphenoid sinus ostium (figure 1, A). Coronal computed tomography (CT) of the sinuses demonstrated lobulated opacification of the inferior half of the left sphenoid sinus (figure 1, B).

After antibiotic therapy was completed, the endoscopic examination revealed resolution of the purulent drainage and the presence of a narrowed, slit-like sphenoid sinus ostium (figure 1, C) with mild edematous swelling along the lateral aspect of the ostial opening (figure 1, D).

Because of the recurrent and symptomatic nature of the patient's sphenoid sinus infections, balloon dilation of the left sphenoid sinus was offered as a treatment option. She wished to pursue balloon sinuplasty. She would not tolerate an in-office procedure, and thus the procedure was performed with the patient under general anesthesia.

[FIGURE 2 OMITTED]

The ostium of the sphenoid sinus was identified using a 0[degrees] endoscope. The sphenoid sinus guide was placed anterior to the sphenoid sinus ostium (figure 2, A), and the lighted guide wire was readily advanced into the sphenoid sinus. A 6 x 16-mm balloon was then advanced over the guidewire and inflated to 10 atmospheres to dilate the ostium (figure 2, B). After the balloon was deflated and withdrawn (figure 2, C), the sinus was irrigated with a copious amount of sterile saline until the sphenoid sinus was clear of mucus and purulent fluid. The ostium was noted to be widely patent and measured 6 mm in diameter (figure 2, D).

The patients symptoms markedly improved. Followup endoscopic examination confirmed maintenance of ostial patency, and she has remained infection free for 18 months.

Balloon catheter dilation of paranasal sinuses continues to gain popularity as a treatment for chronic rhinosinusitis, (1) although varying levels of acceptance and confidence exist. (2) In a recent study by Levy et al, improvements after balloon dilation were noted in quality of life measures (SNOT-20) and sinonasal opacification (Lund-Mackay scores). (3) The treatment of refractory sphenoid sinusitis has traditionally been directed at draining the sphenoid sinus through its natural ostium medial to the superior turbinate, or through a trans-ethmoid route. The natural sphenoid sinus ostium is often amenable to balloon dilation, which can be performed in the office under local anesthesia or in the operating room under general anesthesia.

Although the sphenoid sinus does not transilluminate as brilliantly as the frontal or maxillary sinuses with a lighted guidewire, transillumination upon successful cannulation can be reliably noted in the mid and inferior portions of the sphenoid sinus when correct access has been obtained. (4) Dimming the endoscope light source can aid in visualizing the "glow" of light within the sphenoid sinus cavity from the tip of the lighted guidewire. Also, computer navigation devices, which have been used frequently in the operating room, are becoming increasingly available for use in the office and can be useful for confirming and identifying the location of the sphenoid sinus ostia, especially in cases with aberrant or distorted anatomy.

Balloon dilation of the natural sphenoid sinus ostium offers the sinus surgeon another method to safely and effectively treat inflammatory sphenoid sinus disease. Further research into delineating ideal candidates for balloon catheter dilation is required to better evaluate indications, outcomes, and complications, as well as distinctions between operating room and office procedures. (3,4)

References

(1.) Catalano PJ. Balloon dilation technology: Let the truth be told. Curr Allergy Asthma Rep 2013;13(2):250-4.

(2.) Batra PS. Evidence-based practice: Balloon catheter dilation in rhinology. Otolaryngol Clin North Am 2012;45(5):993-1004.

(3.) Levy JM, Marino MJ, McCoul ED. Paranasal sinus balloon catheter dilation for treatment of chronic rhinosinusitis: A systematic review and meta-analysis. Otolaryngol Head Neck Surg 2016;154(l):33-40.

(4.) Yanagisawa K, Christmas DA, Mirante JP, Yanagisawa E. Endoscopic view of sphenoid sinus illumination and transillumination. Ear Nose Throat J 2014;93(2):56-7.

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

From the Section of Otolaryngology, Yale New Haven Hospital, Saint Raphael Campus, and the Section of Otolaryngology, Yale University School of Medicine, New Haven, Conn. (Dr. K. Yanagisawa and Dr. E Yanagisawa); the Section of Otolaryngology, Halifax Medical Center, Daytona Beach, Fla. (Dr. Christmas and Dr. Mirante); and Florida State University School of Medicine, Daytona Beach (Dr. Mirante).
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Title Annotation:RHINOSCOPIC CLINIC
Author:Yanagisawa, Ken; Christmas, Dewey A.; Mirante, Joseph P.; Yanagisawa, Eiji
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Date:Aug 1, 2016
Words:793
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