What are the differences between endoscopic sinus surgery vs balloon sinus surgery?

Doctor's Answers 1

What is endoscopic sinus surgery?

Endoscopic Sinus Surgery (ESS) is simply any surgical procedure for the sinuses performed through the nostrils and visualised with an endoscope. When sinus surgery is performed to treat a condition e.g. sinusitis (inflammation or infection of the paranasal sinuses), and we want to maximise the chance of the sinus returning to normal function, this is called Functional Endoscopic Sinus Surgery (FESS). FESS is thus the most common type of ESS.

What is balloon sinuplasty?

Balloon sinus surgery (sinuplasty) is one of the techniques for widening the opening to the sinuses and is essentially a small subset of FESS used by some surgeons.

Balloon sinuplasty -- least invasive sinus surgery

It is commonly promoted as the most minimally invasive type of sinus surgery. In a consensus statement, the pre-eminent rhinology experts from across the globe in 2016, balloon sinuplasty for the frontal sinuses was classified as Grade 0 frontal sinus surgery (International Forum of Allergy and Rhinology 2016;6(7):677-696).

Balloon sinuplasty is an option but its usefulness needs to be considered against the actual condition that is being treated (which is different for each patient) and the preferences of the patient and surgeon.

Let me try to explain, using the frontal sinus as a case study

In general, the pathway of drainage and aeration of the frontal sinus is the most complex of all the sinuses; furthermore, it varies from person to person and even from side to side for the same patient. If you think of it as a home, it is like a narrow and twisted corridor leading to your master bedroom. Along this pathway are the sinus cells which are like smaller rooms lining the corridor. If your aim is to clear a pathway to the master bedroom, you could remove all the partition walls that together form all the smaller rooms.

This is what standard FESS should aim to do.

In balloon sinuplasty, a balloon catheter is inserted into the frontal sinus and inflated, thereby widening the pathway to the diameter of the balloon (usually 4mm). In the process, the surrounding cells are crushed. In the corridor analogy, this is like crushing all the side rooms to widen the corridor to the master bedroom.

With balloon sinuplasty, the pus in the frontal sinus is drained and the small crushed cells tend to resolve naturally. However, it is theoretically possible for the crushed cells to continue to harbour infection, and sometimes, it does.

So in the analogy of the master bedroom, you manage the master bedroom but you leave the fate of the small crushed rooms to chance.

How is balloon sinuplasty used most often these days?

Balloon sinuplasty is used most often for the frontal sinuses. However, frontal sinus infections seldom occur in isolation, i.e without the surrounding ethmoid sinuses also being affected. For this reason, we often hear of FESS where standard surgical techniques are combined with balloon sinuplasty for the frontal sinuses. This is the most common type of hybrid FESS, which has been advocated as an innovation in FESS.

While hybrid FESS sounds like a better deal than standard FESS, the term “hybrid” actually just means what it means. My personal opinion is that, if I am doing a FESS, there is little added advantage for the patient for me to do a balloon sinuplasty for the frontal sinuses as opposed to standard surgery (i.e clearing all the cells as described above).

The potential advantages of a comprehensive clearance are:

  • the final opening to the frontal sinuses is not limited to the size of the balloon (typically 4 mm)
  • there are no crushed cells that need to be cleared of infection by change
  • the cost of a balloon is saved

Is there any benefit of a larger opening?

Yes, there are clear advantages:

  • It is easier for the patient to flush the sinuses with nasal irrigation a.k.a nasal saline douche in the post-operative period. This means patients can experience a quicker recovery.
  • If the patient gets sinusitis in the future, it will probably clear much more quickly with a larger opening.
  • There is less need for in-clinic instrumentation (e.g flushing and suctioning) of the sinuses, which is time-consuming and uncomfortable for the patient.
  • Even if instrumentation is required, it will be much more comfortable for a patient with a wide frontal opening compared with having one that is barely wider than the instrument.

When will I use balloon sinuplasty?

There are limited situations where balloon sinuplasty can be really useful:

  • isolated sinus (frontal, maxillary or sphenoid) bacterial (but not fungal) infection

  • when a patient is not fit for general anaesthesia; i.e balloon sinuplasty under local anaesthesia

  • E.g a pregnant lady trying to avoid long term medications or surgery in view of the child)

  • when the risk of bleeding cannot be reduced

  • E.g a patient on antiplatelet medications to prevent heart attack -- it would be too risky to stop the medication and risk a heart attack just to get FESS done)

In my opinion, balloon sinuplasty is ideal if:

  • you have subacute sinusitis i.e sinusitis >4 weeks but <12 weeks of sinusitis - it is essentially the transition or grey area between acute sinusitis and chronic sinusitis
  • you do not want general anaesthesia -- you are willing and actually want a procedure done while you are awake
  • you want minimum downtime from a standard FESS -- you may want to return to normal activities the very next day
  • you do not want to keep taking antibiotics for the sinusitis not knowing when or whether it is going to resolve

If balloon sinuplasty is being proposed, it is important to find out if there are special reasons for this:

  • I have listed above specific situations for which I might propose balloon sinuplasty; however, these are neither common nor the norm

  • Does the surgeon feel that the outcome is going to be better than standard surgery? For example, if the reason to use the balloon is to minimise scarring of the frontal pathway.

  • This is a valid reason if the surgeon feels that the risk of scarring is higher for standard surgery in his/her hands. However, this is certainly not the experience in the majority of tertiary hospitals around the world.

Conclusion

Balloon sinuplasty is a specific technique for widening the opening to the frontal, maxillary or sphenoid sinus. It is a small subset of the techniques that can be employed in endoscopic sinus surgery. It offers an alternative that works well for milder disease and the benefit of minimal recovery time.

However, there is no evidence, at all, that it offers any advantage for more extensive sinusitis or for chronic sinusitis with nasal polyposis (CRSwNP) or for fungal sinusitis. When considering balloon sinuplasty, one should understand clearly what advantage he/she will have from hybrid FESS with balloon sinuplasty versus FESS with standard surgical techniques.

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