Rhinology (Allergy & Sinus) : Rhinology Procedures and Treatments

Rhinology Procedures and Treatments

BALLOON CATHERTERS IN SINUS SURGERY

In 2005, the first commercially available product using balloon dilating catheter technology was released to treat sinus disease. Overall, the concept is simple. A guidewire is passed from the nasal cavity into the specific sinus that is being addressed. Once it has been confirmed that the guidewire is in the sinus, a balloon dilating catheter is passed over this wire to the narrowest part of the sinus drainage pathway. This high pressure balloon is briefly inflated, and the pressure of the balloon widens the outflow tract of the sinus by fracturing bone and moving it outwards, along with its mucous membrane. The final result is a dilated or widened outflow tract from the sinus that can be done without actual tissue removal.
Although this technology initially was met with criticism, clinical studies have demonstrated that it is a safe tool in the management of chronic sinusitis. The American Rhinologic Society as well as the American Academy of Otolaryngology-Head and Neck Surgery both currently have favorable position statements concerning this technology. These devices are FDA approved and have been used on tens of thousands of patients.
To simplify things, the balloon dilating catheter can be used in 2 ways. One way is to use it just like any other instrument or tool used during functional endoscopic sinus surgery- it is used as a minimally invasive tool during a procedure where tissue is actually removed. Another way that it can be used is as a stand-alone procedure — that is when only the balloon and no other instrumentation is used to open a sinus. With this technique, no tissue is actually removed from the level of the sinus opening. It has been shown that use of minimally-invasive instruments may result in less postoperative pain, less postoperative pain medication use, and a quicker recovery. It cannot be used in all situations, and it cannot be used in all sinuses. It is one of a vast armamentarium of instruments that a surgeon may choose from in different surgical situations.
Even over the last several years, there have been advances in balloon technology. Initially, to confirm that a surgeon was in a sinus, an x-ray machine had to be used during surgery to confirm correct placement of the guidewire. This exposed patients to intraoperative radiation that they would not otherwise get with standard instrumentation. Now, sinus access can be confirmed with a lighted guidewire- one with a bright fiberoptic light at the end of the flexible guidewire or by using navigational systems that make use of the imaging studies done prior to the surgery as part of the normal diagnostic workup.

TURBINATES

The turbinates are structures on the side wall of the inside of the nose. They project into the nasal passages as ridges of tissue. The turbinates help warm and moisturize air as it flows through the nose. The inferior turbinates can block nasal airflow when they are enlarged.
The turbinates are made of bone and soft tissue. Either the bone or the soft tissue can become enlarged. In most patients, enlargement of the soft tissue part of the turbinate is the major problem when the turbinates become swollen. When the turbinates are large, they are called hypertrophic turbinates.

DIAGNOSIS

The diagnosis of enlarged inferior turbinates can be made by your doctor with a thorough evaluation of your symptoms and nasal examination. Your doctor may perform a procedure in the office called a nasal endoscopy to diagnose the cause of your nasal obstruction.
After making the diagnosis, your doctor can discuss treatment options for you. If the turbinates are swollen, your doctor may recommend medications for you. For many patients, medications can help reduce the size of the turbinates and can help improve their nasal obstruction. If you have troublesome symptoms even after using medications, you may be a candidate for surgery to shrink the size of your turbinates.

SURGERY

There are many ways to shrink the size of the turbinates. Surgery is typically called turbinate reduction or turbinate resection. Surgery can be performed either in the office or in the operating room. In many instances, turbinate surgery and septoplasty are performed at the same time.
It is important that the turbinate not be removed completely because that can affect the function of the turbinates. Complete turbinate removal can result in a very dry and crusty nose. Occasionally, turbinate tissue will re-grow after turbinate surgery and the procedure may need to be repeated. This is preferable to the situation of totally removing the turbinate.
You may hear of many different terms being used when it comes to surgery for the turbinates. Examples of these terms are cauterization, coblation, radiofrequency reduction, microdebrider resection, and partial resection. These all refer to different methods of reducing the size of the turbinates.
Some of these methods shrink the turbinates without removing the turbinate bone or tissue. These methods include cauterization, coblation, and radiofrequency reduction. In each of these methods, a portion of the turbinate is heated up with a special device. Over time, scar tissue forms in the heated portion of turbinate, causing the turbinate to shrink in size.

With some of the other procedures, a portion of the turbinate is removed. It is important that enough of the turbinate be left intact so that the turbinate can warm and humidify the air that is flowing through the nose. A procedure called submucosal resection is a common technique used to treat enlarged turbinates. With this procedure, the lining of the turbinate is left intact, but the “stuffing” from the inside of the turbinate is removed. As the turbinate heals, it will be much smaller than before surgery. Sometimes, this resection can be performed with a device called a microdebrider. This device allows the surgeon to remove the “stuffing” through a small opening in the turbinate. In some instances, more of the turbinate is removed.
In some instances, packing may be placed in your nose during the healing process.

POST-OPERATIVE CARE

You can expect to have pain, fatigue, nasal stuffiness, and mild nasal drainage after your surgery. Pain is generally mild with this type of surgery and is typically well controlled with pain medications by mouth. The stuffiness typically results from swelling after the procedure, and typically starts to improve after the first week. You may have drainage of some mucus and blood from your nose after surgery. This is a normal part of the healing process.
You may be asked to use saline sprays or irrigations after your surgery. Please check with your surgeon about any post-operative care you will need to perform to allow your nose to heal properly.

RISKS OF SEPTAL AND TURBINATE SURGERY

As with any surgical procedure, septal and turbinate procedures have associated risks. Although the chance of a complication occurring is very small, it is important that you understand the potential complications and ask your surgeon about any concerns you may have.
Bleeding: Most nasal surgery involves some degree of bleeding, which is generally well tolerated. In very rare situations, significant bleeding may require termination of the procedure. Blood transfusion is rarely necessary and is given only in an emergency. You should stop use of blood thinners such as aspirin, ibuprofen, omega 3 and vitamin E at least a week before surgery. If you require prescription blood thinners, please make sure you discuss this with your surgeon. Your surgeon will provide guidelines on when these medications can be stopped and re-started.
Persistent symptoms: The goal of surgery is to improve the structural problems that are leading to your nasal blockage. A large majority of patients (over 90%) have significant improvement in their nasal obstruction symptoms after surgery. However, many different factors can impact the final outcome, and some patients may have persistent nasal obstruction after surgery. In very rare instances, patients may notice no improvement or worsening of their obstruction symptoms.
Infection: The nose is not a sterile environment, and infection can occur after septal and turbinate surgery. Fortunately, infections after septal and turbinate surgery are rare.
Toxic Shock Syndrome: A very rare infection called “Toxic Shock Syndrome” can also occur, usually when packing is placed, but sometimes when no packing is used. This is a life threatening infection and requires immediate treatment. If you note a change in your blood pressure, heart rate, fever and unusual symptoms of skin discoloration, please notify your surgeon immediately. The incidence of toxic shock syndrome is thought to be less than one case in one hundred thousand septoplasty procedures.
Tooth and nose numbness: The nerves that go to the gums and front teeth of the upper jaw come through the nose. Surgery on the septum can lead to stretching or injury to these nerves. This can lead to some numbness of the incisors of the upper jaw. In most instances, the numbness is temporary. Similarly, the tip of the nose may be numb after septoplasty. Sometimes, sensation can take weeks or even months to return. Temporary numbness or pain in these teeth postoperatively is common, but it almost always resolves within several months. Rarely, some patients can have persistent numbness of this area.
Septal perforation: A septal perforation is a hole in the nasal septum. This can develop during or after surgery, especially if there is an infection. Sometimes, a perforation can lead to crusting and obstruction. Great care is taken during your procedure to prevent such a complication, but there is still a small risk this may occur. If the perforation does not cause any symptoms such as bleeding or crusting, then nothing further need be done. For symptomatic perforations, surgical closure or placement of a synthetic septal button can be performed.
Spinal fluid leak: Because the top of the nasal septum is located below the skull, there is a rare chance of creating a leak of cerebrospinal fluid (the fluid that surrounds and cushions the brain) or injuring the brain. Should the rare complication of a spinal fluid leak occur, it may create a potential pathway for infection, which could result in meningitis. If a spinal fluid leak were to occur, additional surgery and hospitalization may be necessary. This is an extremely rare problem after septoplasty.
Other risks: Other uncommon risks of surgery include alteration of sense of smell or taste; persistence and/or worsening of facial pain; change in the resonance or quality of the voice; and swelling or bruising of the area around the eye. There is a very small risk of a subtle change in the external appearance of the nose after a septoplasty.

OPEN SINUS SURGERY

In some cases, a benign sinus tumor or a sinus cancer may be in a difficult-to-reach location or may need to be removed along with bone, fat and even skin. Again, the amount of surgery and the route of surgery depends on what type of tumor you have and on whether it can be safely and adequately removed. In some cases, an incision must be made on the face or scalp to assist in removing tumors completely. In the case of sinus cancers, incisions on the face or scalp may need to be done in order to remove all the tumor successfully.

ADDITIONAL THERAPY

If the tumor is benign, it is unliekly that you will need any other medical therapy following the removal of the tumor. The ENT surgeon may request that you return for additional visits so exams can be performed. You may also need to have additional CAT scans or MRIs to determine if the tumor has come