(Dr. Woodworth)
(Dr. Sillers)
Undoubtedly you have heard much of the discussion about balloon sinuplasty (BSP). What is it and where does it fit into the spectrum of treating patients with sinusitis, in particular those who fail medical therapy and are candidates for surgical intervention? 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 and the ethmoid sinus is not directly treated. Studies have shown that it can safely and effectively open a sinus outflow tract and it 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 appropriately selected patients.
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 traditional 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 without concomitant septal and/or turbinate surgery. 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, effective, and is performed with minimal morbidity. More controversial is the use of BSP in patients with a history of recurrent sinus infections (recurrent acute rhinosinusitis) but demonstrate no radiographic evidence of sinus 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. The surgical management of a deviated nasal septum (septoplasty) and enlarged inferior and middle turbinates (turbinoplasty) 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.
In an era of cost containment one important topic to address regarding BSP is the addition of disposable devices. This technology is not inexpensive and tends to add approximately $1000/case. This additional cost may be partially offset by the potential reduction in 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 setting and does not reimburse when the appropriate CPT codes for balloon sinus dilation are utilized.
Balloon sinuplasty is exciting technology and represents an advance in our efforts to pursue less invasive methods for treating patients with refractory sinus disease. Its use is indicated in patients with demonstrable inflammatory disease of the maxillary, sphenoid, and frontal sinuses. Traditional functional endoscopic sinus surgery is still the method of choice in treating patients with advanced disease.
Brad Woodworth, MD, FACS James J. Hicks Associate Professor of Surgery Otolaryngology-head and Neck Surgery, UAB
Michael J. Sillers, MD, FACS Clinical Professor of Surgery Otolaryngology-Head and Neck Surgery, UAB Alabama Nasal and Sinus Center
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