Minimally-Invasive Sinus Surgery

Minimally invasive sinus surgery

Minimally-invasive Sinus Surgery

.When Surgery to Treat Sinusitis is Needed.

Part 2

When considering surgery for a child with chronic sinusitis …

When all else fails …

Last week I reviewed the first step in surgery to treat your child’s chronic sinusitis – adenoidectomy. We also talked about sinus centesis and new methods for identifying the bacteria that are causing the problem. Check out this link for Part 1 of “When Your Child Must Have Sinus Surgery“.

So, let’s assume that you have done EVERYTHING to eliminate your child’s chronic sinusitis. Let’s assume that you have followed my 5-Step Program to Eliminate Biofilm and Chronic Rhino-Sinusitis.

If all else fails and sinus surgery is absolutely indicated – perhaps your child has experienced one of the severe Complications of Sinusitis – the approach should always be minimally-invasive surgery:  minimal surgery for maximal gain, especially for a child.

Image: Balloon Sinuplasty Catheter

My own minimally-invasive preference for sinus surgery is “balloon sinuplasty” when possible, since there is minimal scarring, minimal post-operative crusting and bleeding, and excellent sinus openings are achieved. This is the method that I have been using for at least 5 years with great success.

This approach, balloon sinuplasty, has been found to have lasting results in adults.  Dr. Ramadan recently reported that balloon sinuplasty is also safe and effective in children, corroborating my own experience (Ramadan, 2009). In fact, there is a huge number of medical studies now that report excellent long-term results for Balloon Sinuplasty – with somewhere over 3,000 patients now!

Balloon Sinuplasty for Chronic Sinusitis

Image: Medical Studies on Balloon Sinuplasty for Chronic Sinusitis

How Does Balloon Sinuplasty Work?

Most people have heard of cardiac balloon catheters – those are the balloons that are placed into the coronary arteries, and expanded to open the arteries, as an alternative to coronary artery bypass surgery.

For balloon sinuplasty, a similar balloon catheter is placed into the normal openings of the sinuses (called the sinus ostea), and expanded to stretch open the ostea. [Check here for the Anatomy of the Nose and Sinuses].

Balloon Sinuplasty: No cutting. No tearing or ripping the tissue. As a result, there is less bleeding, less potential for scarring, less post-op care required at home, and in clinic. Long-term follow up has shown excellent results.

The 4 steps to Balloon Sinuplasty:

  1. Placethe Balloon Catheter

    Balloon Sinuplasty to Treat Chronic Sinusitis

    Image: Balloon Sinuplasty to Treat Chronic Sinusitis – Placing the Balloon

  2. InflateBalloon CatheterBalloon Sinuplasty to Treat Chronic Sinusitis
  3. DeflateBalloon CatheterBalloon Sinuplasty to Treat Chronic Sinusitis
  4. Removethe CatheterBalloon Sinuplasty to Treat Chronic Sinusitis

Images courtesy of Frederick Kuhn, MD

All of these steps in children require a general anesthetic. For adults, some sinus surgeons are actually offering Balloon Sinuplasty in their clinics, without the need for general anesthetic.

Results:

Overall, my pediatric patients have achieved greater than 90% success with balloon sinuplasty! That is impressive, given that I will only perform sinus surgery for those children who fail every other possible medical and surgical treatment – including long-term nasal saline rinses, long-term antibiotics, and an adenoidectomy – before I will consider sinus surgery. That means that these children have chronic sinusitis that is particularly difficult to treat, by ANY means.

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Watch the Balloon Sinuplasty Video / animation:

 

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Transparency: I have no financial or other ties to the vendor of this surgical system (Acclarent Medical). I recommend those who are curious to check out their website.

Important:

If the care of your child does progress to the point of sinus surgery, keep in mind that exposure to tobacco smoke will significantly reduce the success rate of the surgery (Ramadan & Hinerman, 2002). Just one more reason to Quit Smoking (do it for your kids!), and to Eliminate Your Smoke Exposure – keep smokers away from you and your children!

Resources

Ann L. Griffen, Clifford J. Beall, Noah D. Firestone, Erin L. Gross, James M. DiFranco, Jori H. Hardman,Bastienne Vriesendorp, Russell A. Faust, Daniel A. Janies, Eugene J. Leys.CORE: A Phylogenetically-Curated 16S rDNA Database of the Core Oral Microbiome; PLoS ONE, 2011: http://www.plosone.org/article/info:doi%2F10.1371%2Fjournal.pone.0019051

Faust RA and Rimell FL: Chronic rhinosinusitis in children. Current Opinion in Otolaryngology, Head and Neck Surgery, vol. 4: 373-377, 1996.

Ramadan HH, Cost JL: Outcome of adenoidectomy versus adenoidectomy with maxillary sinus wash for chronic rhinosinusitis in children. Laryngoscope Vol. 118: 871-873; 2008.

Ramadan HH: Safety and Feasibility of Balloon Sinuplasty for Treatment of Chronic Rhinosinusitis in Children. Annals of Otology, Rhinology & Laryngology. Vol. 118(3): 161-165; 2009

Ramadan HH, Hinerman RA. Smoke exposure and outcome of endoscopic sinus surgery in children. Otolaryngology Head & Neck Surgery. Vol. 127(6): 546-548; 2002.

Acclarent Balloon Sinuplasty:  https://www.acclarent.com/solutions/sinusitis-overview/balloon-sinuplasty-technology

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Russell Faust boogordoctor Pediatric Sinusitis Unified Airway

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Comments

  1. Stephanie says:

    Would you recommend the balloon sinus surgery for a 6 year old if he already had his adenoids out and a sinsus puncture and flush done with no relief? We have tried prolonged antibiotics and sinus flushes. Would the balloon procedure provide a better outcome than the sinsus purcture and flush? Arent they similar procedures?

    • Russell A. Faust, PhD, MD says:

      Hi Stephanie,
      Thanks for visiting, and for sharing!
      I am a big proponent of minimally-invasive surgery, especially if a child needs surgery. Balloon Sinuplasty is the best approach for a child, if they require sinus surgery. I agree with the treatment that you have already undergone. It sounds like you are in good hands. The “puncture and flush” merely rinses the sinus out at the time of the surgery. It does nothing to keep the openings of the sinuses open. It is great to clean out a sinus, and it is great to get a sample from a sinus for culture to see what micro-organisms are involved. If you are to the point that your 6-year-old needs to have the sinus openings enlarged for optimal long-term health, Balloon Sinuplasty is far less invasive than the traditional approaches to sinus surgery, involves no cutting or tearing, or removal of normal tissues. It simply opens the sinuses. The maker of the Balloon Sinuplasty catheters, Acclarent, has a good website for further information. Transparency: I have no relationship, financial or otherwise, with Acclarent.
      I wish you best success, and hope that surgery is NOT required. Please stop back and share how you are doing.
      Thanks,
      RF

  2. Freida Wilms says:

    Two questions: 1. If one is having FESS for to do a deviated septum correction, does one need to be under general anesthesia or can sedation anesthesia used instead? I may have surgery to correct a deviated septum and I do not want general anesthesia.

    2. Is it common for a concha bullosa to block the openings of the sinus passages? I have one in my CT scan and the doctor did not mention if it was a problem for me or not, but I do have deviated septum. Is the surgery to correct that issue a complex one? Can they do a combo surgery of concha reduction at same time as septum deviation?

    • Russell A. Faust, PhD, MD says:

      Hi Freida,
      Thank you for visiting, sharing, and asking.
      Repair of a deviated nasal septum does not require general anesthetic. On the other hand, I’m pretty certain that I would want to be completely under to have surgery to correct my own deviated septum! Most surgeons DO prefer general anesthetic for a FESS (functional endoscopic sinus surgery). Recently, there are a very few surgeons who consider local anesthetic for “Balloon Sinuplasty” – a minimally-invasive approach to opening the sinuses using a balloon that is similar to the balloons used to open coronary arteries. If interested, check out the article on this site, or take a look at the Acclarent site, maker of the balloon (www.sinussurgeryoptions.com). Balloon Sinuplasty is the approach that I use for my own patients when all else fails.
      Regarding concha bullosa: yes, they can obstruct the sinus openings. Whether your concha bullosa is a problem is something to explore on your CT scan with your ENT doc. Removing a concha bullosa is usually not very complicated, but may require a general anesthetic.
      Thanks again for visiting, and best success with your septum, sinuses, and concha! Please visit again and let us know how things work out.
      RF

      • Freida Wilms says:

        One other question I had: How many CT scans does one person need when undertaking FESS? I had a CT scan to show that I actually needed surgery…would that CT scan be used for my pre-planning or are multiple scans needed? My doctor has the xorantech in-office scanner.

        • Russell A. Faust, PhD, MD says:

          Hi Freida,
          How many CT scans are needed to prepare for sinus surgery? Depends. Usually only one, but some surgeons will use an initial CT scan to evaluate the extent of disease, often done in their office or clinic using one of the smaller CT scanners; but then will want a more detailed, high-resolution CT scan for surgery. If there is extensive disease, or disease in the frontal or sphenoid sinuses, some sinus surgeons will use a “stealth” or “Landmark” CT scan that reconstructs the images in 3-dimensions in the computer. These systems are impressive, and can help locate the surgeons’ instruments in 3-D within the CT scan, in real-time, during surgery. That is, while the surgeon has the instrument inside the patient’s sinuses, the instrument is shown on a monitor inside the 3-D CT scan in real-time. This helps localization in challenging cases.
          Best success with your sinus surgery!! And let us know how things go for you.
          Thanks for visiting and sharing.
          RF

          • Siavash Kamaliasl says:

            Hi Dr. Faust
            Do you recommend balloon sinuplasty for a 11 years old boy with racurrent acute sinusits (more than 6 time a year from infancy afterward) ,normal adenoid and immune system who probably has narrow ostiae or narrow nose , he is my son . with regards Siavash Kamaliasl

          • Russell A. Faust, PhD, MD says:

            Hi Siavash,
            IF a child warrants sinus surgery, balloon sinuplasty is my approach. But that is a big “IF.” Of several hundred children who have been referred to me explicitly for “sinus surgery,” I have succeeded in keeping nearly 90% of them healthy without sinus surgery. That is not to say that other surgery – specifically, adenoidectomy – was not necessary. Even when the adenoids are not obstructing the back of the nose (and causing things like obstructive sleep apnea), studies show us that the adenoids act as a reservoir for bacteria that cause sinusitis. When everything else has failed – and that is a long list of options – my first SURGICAL approach is to perform an adenoidectomy to eliminate that reservoir of bacteria. Even “normal adenoid” has been shown to harbor pathogenic bacteria. And “sinus surgery,” balloon sinuplasty or traditional sinus surgery, does little to open a ‘narrow nose.’
            Thank you for sharing, and best success!
            RF

  3. Dear Dr. Faust,
    My son is 9 and has had tonsils, adenoid removed and sinus surgery by age 4. Our problem now is that his nose doesn’t work at night. He gets terrible sleep because hehas to mouth breathe. The steroid nose sprays don’t help enough. Oxymetazalone has its clear limitations. I don’t want him on steroids or sudafed forever either. The allergy doc had him on so many other sprays that my son developed fissures and bleeding from the dryness and trauma the sprays and the ENT took him off all the sprays cold turkey. We are back on OTC steroid spray and it really isn’t sufficient. If he needs turbinate reduction (suspect this), what method do you recommend? I’d like to know before I take him to the ENT. I had turbinate reduction and septoplasty about 23 years ago and it was fantastic. I think I need a touch up myself as breathing is very difficult at night for me too, unless I use the dreaded Afrin. The nasal rinses haven’t kept the night swelling at bay, unfortunately. Thanks for any suggestions and your time!

    • Russell A. Faust, PhD, MD says:

      Hi C.A.,

      Unfortunately, there’s just no way for me to know what is going on in your son’s nose and sinuses without examining him…just not possible :(

      But to answer your question about turbinate reduction: there are straight surgical methods – meaning, removing portions of the turbinates; and there are “ablation” methods, including electrocautery and “coblation,” and perhaps others.

      Consider doing a search on “turbinoplasty methods” and “coblation turbinoplasty.” I have used all methods. In my opinion – if my own child or myself – I would be looking for an ENT surgeon who does nothing except nasal procedures…sinuplasty, septoplasty, turbinoplasty, etc. An ENT doc who does only occasional turbinoplasty won’t have the experience for consistent, reliable results. And a ‘botched’ turbinoplasty can result in “dry nose syndrome” and other undesirable outcomes.

      My advice: find an expert, preferably a Pediatric ENT doc who specializes in the nose. That would be a challenge even in NYC, LA, or any huge metropolis, but if you are in Alabama, you have access to an outstanding Pediatric ENT doc: Look for Dr. Audie Woolley at Pediatric ENT Associates in Birmingham. (for transparency: I have no relationship with Dr. W., Pediatric ENT Associates, financial or otherwise).

      Best success! And please let me know how things go :)

  4. Hi Dr Faust,
    My son (5yrs old) has had chronic sinusitis since I can remember. He always has “allergy symptoms” however he has been allergy tested and is not actually allergic to anything accept cats. (We do not own a cat) He recently had a CT done that showed pansinusitis. The poor guys has headaches & restless sleep.
    He does not have much post nasal or any nasal drainage. Its all impacted in his sinuses I suppose.
    After reading some of your blogs I began the saline rinse twice a day. After 10 days he began getting nose bleeds so I continued once a day with saline spray and the nose bleeds resolved.
    Here’s my question. His ENT treated him with 3weeks of cifdinir, along with the saline. His symptoms might be a hair better, but not much. Today his ENT suggested adenoidectomy (I knew that was coming) and balloon sinuplasty (was not expecting that)
    I’m a little aprehensive about the balloon. I have read everything I can read about it. I know you reccommend adenoidectomy first, and the balloon only as a last resort.
    Do you ever reccommend a child having testing done for cystic fibrosis before having the balloon sinuplasty?

    My son has not had any red flags for CF besides the pans sinusitis.

    • Russell A. Faust, PhD, MD says:

      Hi Kelly:
      Your son’s ENT may have good reasons for their recommendations…I would give them the ‘benefit of the doubt,’ and ask. Call. Leave a message that you have questions.

      An adenoidectomy is never a bad thing, in my not-so-humble opinion: gets rid of a potential reservoir of pathogenic bugs; removes potential upper airway obstruction. And regarding balloon sinuplasty, if the surgeon is experienced there is little potential down-side – especially compared to “standard” sinus surgery.
      Of course, as a parent, you are anxious and protective of your little guy. But consider the potential to improve his quality of life.

      Sorry I can’t offer direct advice. I see you are in Ohio…FYI, some of the best pediatric sinus docs in the world are at Columbus Children’s (Nationwide), and OSU.
      Thank you for sharing, and please keep me updated!

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