The Case for Minimally Invasive Office-based Sinus Balloon Dilation and Nasal Airway Treatments

A surgeon explains how procedures such as in-office balloon sinuplasty may subjectively improve sleep quality and ultimately improve obstructive sleep apnea treatment compliance in select patients.

The traditional treatments for obstructive sleep apnea (OSA) and snoring are relatively well known, and include various forms and delivery methods of positive airway pressure (such as CPAP), oral and nasal airway appliances, and an ever-expanding variety of airway surgical procedures. The goal of the physician is to get OSA treated in a definitive and/or consistent way, while still bringing improvement to the patient’s subjective complaints.

These various treatments can be quite effective for reducing or eliminating OSA for a number of patients, but as we know, patients aren’t always amenable to undergoing surgery, or aren’t always compliant in using the CPAP or similar devices on a consistent basis. In my opinion, the goal of a good physician is to ultimately bring these patients to the correct understanding of their condition so they may voluntarily and happily move forward with the appropriate treatment. As most of us know, this task can often become more of an art than a science.

For these reasons, in appropriate patients I find it helpful to offer a less invasive treatment alternative that doesn’t involve surgery and can often serve as an adjunct to the more traditional medical and surgical treatment options for obstructive sleep apnea and snoring, should they be required.

For patients in my practice whose OSA and snoring are also associated with sinus and nasal obstruction, I have expanded the treatment options in recent years to include an in-office balloon sinus dilation, or balloon sinuplasty, as well as other in-office nasal airway procedures. These procedures often succeed as standalone treatments to fix or greatly reduce the patient’s symptoms. When they do not, they can often bridge the gap between compliance with CPAP and/or, for patients who are indecisive or remain noncompliant, more definitive surgery.

Ultimately, this allows the ENT [ear-nose-throat] clinician to provide a larger patient population with a non-surgical treatment option that is minimally invasive, yet maximally effective for relieving sinus obstruction and nasal breathing difficulties that may be associated with snoring and obstructive sleep apnea in select cases. Most importantly, in patients who have not come to terms with CPAP compliance or airway surgery to treat their OSA in a definitive manner, a thorough discussion of these less invasive options (whether ultimately performed or not) can often help engage the non-compliant patient into moving forward with appropriate treatment.

The In-Office Balloon Sinuplasty: What Is It?

The in-office balloon sinus dilation, or balloon sinuplasty, is a minimally invasive nasal endoscopic assisted procedure during which a very thin balloon catheter at the end of a handheld tool is inserted into the nose, and subsequently into the affected natural sinus openings, one at a time. This is typically performed in a clinical setting. In my practice, I try to create a spa-like ambiance with mood lighting and music of the patient’s choice to ensure the patient is relaxed during the procedure.

In preparation, the patient’s nose is numbed via local anesthesia—typically a topical numbing agent followed by a local injection of lidocaine when necessary. The balloon at the end of the handheld device is advanced and gradually inflated within each of the sinus cavities to relieve blockages and permanently widen and remodel the sinus outflow pathways. The expansion of the balloon creates an audible cracking noise as it expands the sinus cavity, though the patient does not typically feel any discomfort when this happens. The clinician may choose to warn the patient just before the sound occurs to help assuage any fear. I prefer to warn my patients in advance, telling them that this cracking noise is “the sound of success.”

The expanding of the balloon during the sinuplasty and subsequent cracking of the thin sinus bone surrounding the natural sinus openings (ostia) serves to create a permanent enlargement of the sinus opening. This bone heals in the open position, which creates a stable and essentially permanent fix, thus reducing blockage and improving sinus drainage over the long term. In the vast majority of patients who undergo the procedure, this typically eliminates the nagging sinus discomfort, pressure, and pain associated with obstructed sinuses.1 This may be why a significant number of patients subjectively report better and more restful sleep after treatment with just this standalone procedure.

Balloon Sinuplasty Used in Conjunction with Other Treatments

In addition to balloon sinuplasty, other in-office procedures such as inferior turbinoplasty and middle turbinate concha bullosa resection can augment and improve the nasal airway. In select patients, these associated procedures often make the difference between being able to breathe and sleep with their mouths closed versus open. While not providing treatment for OSA, these adjunct procedures tend to further improve the subjective quality of sleep. With an improved nasal airway, many patients and their spouses report reduced snoring and improved patient compliance with nasal CPAP.

Unlike traditional sinus surgery, balloon sinuplasty and associated office nasal and sinus procedures typically do not require incisions or removal of any bone or tissue. A multi-center study published in the American Journal of Rhinology & Allergy showed that standalone balloon sinus dilation was as effective in treating medically refractory chronic rhinosinusitis as functional endoscopic sinus surgery (FESS), which has been the standard of care for some time.2,3 Further studies reveal that the revision rate of roughly 10% is the same for both traditional sinus surgery and office balloon sinus dilation. Advantages of the less invasive office procedure include minimal damage to surrounding tissue, logarithmic decrease in potential for serious complications, minimal bleeding, and an extremely short recovery time.

Sinuplasty Recovery Period

Because balloon sinuplasty and associated office sinus and nasal procedures are minimally invasive procedures, involving essentially no surgical incisions, potential risks and complications are minimal. For a few days after the in-office procedure, patients may experience minor bleeding or swelling, but any discomfort and other symptoms are generally relieved with over-the-counter medication. Post-procedure recommendations always include saline nasal irrigations as well as gels and emollients.

Most patients experience symptomatic recovery within 1-2 days and experience rapid relief from sinusitis symptoms, including easier breathing and reduction or cessation of facial pain, sinus headaches, sinus pressure, as well as snoring and other sleep problems. Most studies indicate that a majority of patients experience continued sinus health free of associated symptoms for up to two years after the procedure.4 There is every reason to believe that in the majority of cases, the beneficial changes
will be essentially permanent.

Terrance J. Kwiatkowski, MD

Terrance J. Kwiatkowski, MD

Ultimately, if I can utilize a minimally invasive procedure to effectively treat a patient’s condition and bring them some form of lasting relief, that is my first choice as a clinician. If that procedure also bridges the treatment gap, leading that patient to move forward with the correct solution for a potentially more serious condition (such as OSA) when they otherwise would not have done so, then I have made a positive difference in that patient’s life. The office-based procedures described here can often serve that purpose in my practice.

Terrance J. Kwiatkowski, MD, is a board certified otorhinolaryngologist/head & neck surgeon, fellowship trained neurotologist/skull base surgeon, rhinologist/sinus surgeon, and sleep surgeon. He has expertise in providing minimally invasive sinus procedures and rhinologic surgery using the most advanced technologies, including endoscopy and robotics. At miVIP Surgery Centers in Las Vegas, Kwiatkowski utilizes robotics for sleep apnea surgeries that include the uvulopalatopharyngoplasty (UP3), robotic tonsillectomy, and robotic resection of the small oral, tongue, and palate lesions. Visit his practice website at
www.entlasvegas.com, www.sinusol.com, or view his physician profile at http://mivip.com/physician/dr-terrance-j-kwiatkowski-head-neck-surgeon.

References

1. Chandra RK, Kern RC, Cutler JL, et al. REMODEL larger cohort with long-term outcomes and meta-analysis of standalone balloon dilation studies. Laryngoscope. 2016 Jan;126(1):44-50.

2. Cutler JL, Bikhazi N, Light J, et al. Standalone balloon dilation versus sinus surgery for chronic rhinosinusitis: a prospective, multicenter, randomized, controlled trial. Am J Rhinol Allergy. 2013 Sep-Oct;27(5):416-22.

3. Patel ZM, Thamboo A, Rudmik L, et al. Surgical therapy vs continued medical therapy for medically refractory chronic rhinosinusitis: a systematic review and meta-analysis. Int Forum Allergy Rhinol. 2017 Feb; 7 (2): 119-27.

4. Entellus Medical Inc. http://knowledge.entellusmedical.com; http://knowledge.entellusmedical.com/clinical-data, https://www.entellusmedical.com/products/xpress-family

from Sleep Review http://www.sleepreviewmag.com/2018/08/minimally-invasive-office-based-sinus-balloon-dilation/

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