FRONTAL SINUPLASTY P R E P A R E D A N D P R E S E N T E D B Y : D R. Y A H Y A F A G E E H R 4 16/ 12/ 2013
ANATOMY: FRONTAL SINUS Not present at birth Starts developing at 4 years Radiographically visualized at 5-6 years Development not complete until 12-20 years Volume 4-7ml by adulthood No or poor pneumatization in 5-10% Drainage via frontal recess
ANATOMY: FRONTAL SINUS anterior table of the FS is twice as thick as the posterior table The floor of the sinus; supraorbital roof ostium is located in the posteromedial portion of the floor agger nasi cell or ethmoidal bulla can obstruct drainage Drainage depends on the attachment of the superior portion of the uncinate process
ANATOMY: FRONTAL RECESS the most common single site of recurrent or persistent disease after ethmoidectomy BOUNDARIES: Medial: Superior attachment of the MT Lateral: LP Superior: Internal os of the FS Anterior: Posterior buttress nasal spine nasofrontal "beak" Posterior: Superior extension of the EB and SB Inferior: MM
ANATOMY: FRONTAL RECESS
ANATOMY: FRONTAL RECESS
ANATOMY: FRONTAL RECESS
KUHN CLASSIFICATION
ANATOMY: AGGER NASI
ANATOMY: AGGER NASI
TYPE 1 FRONTAL CELL
TYPE 2 FRONTAL CELL
TYPE 3 FRONTAL CELL
TYPE 4 FRONTAL CELL
SUPRAORBITAL ETHMOID CELL Posterior and lateral to frontal sinus Pneumatizes into the frontal bone over the orbit and behind the FS May extend lateral to FS Partition separates this from FS
SUPRAORBITAL ETHMOID CELL
SINUPLASTY PROCEDURE the least invasive of all FS procedures introduced at the AAO in September 2005 stand-alone procedure conjunction with endoscopic frontal sinusotomy identifying the frontal sinus drainage pathway and identifying the air cell walls compromising it identify and treat the frontal sinus more quickly and accurately with less risk of mucus membrane damage
SINUPLASTY PROCEDURE cannulating the frontal sinus and dilating the drainage pathway without damaging the mucociliary clearance mechanism Cell walls in the FR are fractured to widen the FS drainage pathway accomplishes this by: pushing the medial agger nasi cell wall laterally Pushing the ethmoid bulla lamella posteriorly under fluoroscopic/luma light control 70 or 90 guiding cannula in to MM
SINUPLASTY PROCEDURE
SINUPLASTY PROCEDURE image guidance passing the guide wire up into the FS If resistance Fluoroscopy balloon catheter is passed into the FS position checked the balloon is inflated; ends fill first Pressure: 4-6 atm observed fluoroscopically edema
SINUPLASTY PROCEDURE The balloon may be repositioned one or more times over the length of the drainage pathway as needed isolated FS disease or in conjunction with sinuplasty of the MS and SS With Ethmoidectomy > hybrid procedure
SINUPLASTY FLUOROSCOPICALLY
SINUPLASTY FLUOROSCOPICALLY
SINUPLASTY FLUOROSCOPICALLY
SINUPLASTY LUMA LIGHT
FLUOROSCOPY VS. LUMA
SINUPLASTY PROCEDURE
SINUPLASTY PROCEDURE
SINUPLASTY PROCEDURE
SINUPLASTY PROCEDURE
SINUPLASTY PROCEDURE
CONTRAINDICATIONS Extensive polyposis Known skull base trauma or defect
APPLICATIONS AND INDICATIONS Primary surgery Revision surgery Management of post op ostial stenosis Including use in the office Finding the frontal sinus Moving cell walls within the frontal sinus
POSTOP OSTIAL STENOSIS
CELL WALLS WITHIN THE FRONTAL SINUS
MANUFACTURERS Three companies that manufacture balloon catheters have reported their use in endoscopic sinus surgery: Acclarent, Inc Quest Medical, Inc Entellus Medical, Inc
BOLGER ET AL. (2006) 6 human cadever heads, CT before and after balloon dilation Catheters successfully dilated 31 of 31 ostia: 9 maxillary, 11 sphenoid, and 11 frontal recesses Mucosal trauma appeared to be less than that normally seen with standard endoscopic instruments. Minimal trauma to surrounding structures such as the orbit or skull base per CT and nasal endoscopy
BROWN ET AL. (2006) Prospective non-randomized cohort 10 patients, 18 sinuses 10 maxillary, 3 frontal, 5 sphenoid Exclusion criteria: Age < 18 CF Significant nasal polyposis Sinus osteoneogenesis Previous FESS Fluoroscopic guidance with C arm Balloon inflated to mean pressure of 13 atm (range: 10-16)
BROWN ET AL. (2006) No adverse events Minimal bleeding High degree of mucosal preservation Ease of dilation: Sphenoid > frontal > maxillary Mild difficulty in dilating maxillary sinus in 5 of 10 patients Disadvantage: Difficulty to examine ostia postop (uncinate, ethmoid cells not removed)
LEVINE ET AL (2008) Patient Registry retrospective review Multi-center, 27 ENT practices 1036 patients, 3276 sinuses treated 1438 Maxillary, 1284 frontal, 554 sphenoid No major adverse events 2 CSF leaks from ethmoidectomy done by standard FESS 41 of 3276 sinuses required revision (1.3%) 95% patients with symptom improvement Less debridement required for balloon only vs. hybrid
CLEAR STUDY (2008) CLinical Evaluation to confirm safety and efficacy of sinuplasty in the paranasal sinuses Multi-center prospective non-randomized study Bolger et al. (2007): 10 centers (24-week, 109 patients) Kuhn et al. (2008): 7 centers (1 year f/u, 66 patients) Weiss et al. (2008): 6 centers (2 years f/u, 65 patients)
GOALS OF CLEAR STUDY 1) To evaluate the effectiveness of balloon catheter devices in relieving sinus ostial obstruction and in maintaining sinus ostia patency 2) To confirm the safety of sinusotomy using balloon catheters in a larger patient group 3) To gain insight into the ability of sinusotomy with balloon catheters to relieve sinus symptoms, either alone or in combination with standard endoscopic sinus surgery techniques.
INCLUSION & EXCLUSION CRITERIA Inclusion criteria : Adult > age of 18 years Chronic sinusitis unresponsive to medical management Exclusion criteria: Extensive sinonasal polyps, cystic fibrosis Extensive previous sinonasal surgery Extensive sinonasal osteoneogenesis Sinonasal tumors, History of facial trauma Ciliary dysfunction Pregnancy
CLEAR STUDY DESIGN 3 parts, starting with 24-week data, followed by 1-year data and then by 2-year data 2 arms Balloon sinuplasty combined with traditional FESS (hybrid) Balloon sinuplasty alone Nasal endoscopy to assess ostia patency CT sinus/ Lund Mackay scores SNOT-20 survey for sinus symptoms Preop, 24 weeks, 1 year, 2 years postop
SNOT 20 RESULTS Preop: Balloon: 2.09 Hybrid: 2.27 24 week: Balloon: 1.07 (p< 0.0001) Hybrid: 0.92 (p< 0.0001) 1 year: Balloon: 0.99 Hybrid: 0.68 2 years: Balloon: 1.09 Hybrid: 0.64
CT LUND-MACKAY SCORES Preop: Balloon: 5.67 Hybrid: 12.05 24 week: Balloon: Hybrid: No data No data 1 year: Balloon: 1.13 (p=0.07) Hybrid: 1.13 (p<0.001) 2 years: Balloon: 1.75 (p=0.02) Hybrid : 3.25 (p<0.001)
OSTIA PATENCY BY NASAL ENDOSCOPY
REFRENCES An Integrated Approach to Frontal Sinus Surge, Kuhn FA, Otolaryngol Clin N Am, 2006 Catheter-based dilation of the sinus ostia, Bolger WE, Am J Rhinol, 2006 Safety and feasibility of balloon cath. Dilatation of PNSO,annlas of ORL, 2006 Multicentric registry of Ballon sinuplasty, Levine HL, 2008 Kuhn FA. Otolaryngology Head and Neck Surgery (2008) 139, S27-S37 Weiss RL et al. Otolaryngol Head Neck Surg. 2008 Friedman M.Laryngoscope. 2009 Jul;119(7):1399-402