Alabama Nasal & Sinus Center

Alabama Nasal & Sinus Center

Balloon Sinuplasty Revisited.

What’s Up with the Balloon?

imgres 2Undoubtedly you have heard much of the discussion about balloon sinuplasty (BSP).   Numerous advertisements on radio and in print have raised awareness in the public about this relatively new surgical device. What is it and where does it fit in the spectrum of treating patients with sinusitis?

Simply stated, since its introduction in 2005, the balloon is one tool among many that can be used to open a blocked sinus. By using balloon catheter dilation technology to perform BSP, the outflow tracts of the maxillary, frontal and sphenoid sinuses can be dilated. No tissue is removed during BSP.  Importantly, however, is the fact that the ethmoid sinus is not directly treated. 

Studies have shown that it can safely and effectively open a sinus outflow tract.  These studies also demonstrate that the dilated sinus will stay open, so the effect is durable.  Additional studies have shown that this technology can be used safely in the office setting under local anesthesia in appropriate patients.  All of that sounds great.  In truth, it is very exciting that we have a technology that can potentially help a lot of people with minimal pain or time away from normal activities of life. So who is a candidate for BSP?  What needs to be stated is that the indications for sinus surgery have not changed simply because there is a new tool in our tool kit. 

The overwhelming majority of patients with sinus disease improve with medical therapy.  For those patients with chronic rhinosinusitis (defined by 12 weeks of continuous symptoms with endoscopic and/or CT evidence of disease) who do not respond to maximal medical therapy, there is good evidence that they benefit from functional endoscopic sinus surgery (FESS). In a recent prospective study comparing BSP to FESS, BSP was shown not to be inferior to FESS in patients with limited disease who underwent maxillary sinus intervention only.  While this is encouraging for our patients with limited disease this subgroup represents a very small percentage of all CRS patients.  The broad application of this data to patients with advanced disease is controversial at best.  Traditional FESS remains the method of choice and has been shown for over 25 years to be safe and effective.  More controversial is the use of BSP in patients with a history of sinus disease but no radiographic evidence of inflammation, perhaps only radiographic anatomic variations. The consensus opinion of thought leaders in rhinology is that operating on sinuses without evidence of inflammation is not indicated, regardless of the method or tool used [1].  The surgical management of deviated nasal septum and enlarged inferior and middle turbinates without sinus surgery is often effective at relieving symptoms mimicking sinus disease and does not subject the patient to the additional risks and associated costs of unnecessary sinus surgery.

One final topic to address regarding BSP is cost. This technology is not inexpensive and tends to add approximately $1000/case. This additional cost may be justified by the potential reduction in the cost of post-operative care. However, currently in Alabama, Blue Cross Blue Shield does not consider BSP a covered benefit in the operating room or the office.

All told, the balloon is a valuable tool that can be very effective, when used at the appropriate time in patients who are candidates for endoscopic sinus surgery as treatment for refractory chronic rhinosinusitis.  However, the balloon does not and should not expand the indications for endoscopic sinus surgery.  Medical therapy remains the standard of care for most patients with chronic rhinosinusitis.
 
1.European Position Paper on Rhinosinusitis and Nasal Polyps 2012.  Rhinology, supplement 23: 1-299, 2012.

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