Revision frontal sinusotomy using stepwise balloon dilation and powered instrumentation

Authors

  • Naveen D. Bhandarkar MD,

    1. Division of Rhinology and Sinus Surgery/Oregon Sinus Center, Department of Otolaryngology–Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A.
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  • Timothy L. Smith MD, MPH

    Corresponding author
    1. Division of Rhinology and Sinus Surgery/Oregon Sinus Center, Department of Otolaryngology–Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A.
    • Division of Rhinology and Sinus Surgery, Department of Otolaryngology –Head and Neck Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., PV-01, Portland, OR 97239
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  • The authors have no funding, financial relationships, or conflicts of interest to disclose.

Abstract

Objectives/Hypothesis:

To report a novel approach toward revision frontal sinusotomy using a technique of balloon dilation followed by the use of powered instrumentation.

Study Design:

Case report.

Methods:

The frontal sinus outflow tract location was first confirmed with image guidance and then dilated with a balloon to address the soft tissue stenosis. Subsequently, the drill was introduced to accomplish a Draf 2B frontal sinusotomy.

Results:

An advantage of initial balloon dilation of the frontal sinus outflow tract was to quickly address the soft tissue stenosis with minimal tissue trauma and therefore less bleeding. This subsequently enabled insertion and clear visualization of the entire drill bit within the inferior aspect of the frontal outflow tract. The increased visualization makes other instrumentation safer as well, and avoids relatively blind removal of scar tissue that could result in inadvertent entry into the orbit or skull base.

Conclusions:

We describe the utility of the balloon as a tool for revision frontal sinusotomy to efficiently and safely allow subsequent instrumentation of the frontal outflow tract with larger more aggressive instruments, such as the drill. We have found this to be a safe and effective technique provided proper preoperative patient selection and assessment for limiting factors. Laryngoscope, 2010

INTRODUCTION

Drill-out type frontal sinusotomy procedures, specifically the Draf IIB and III,1 are indicated when more conservative procedures have failed to produce long-term patency of the frontal sinus outflow tract (FSOT). Anatomy is distorted and complex in these situations, with the cicatrix in the FSOT often involving an inferior “soft” stenosis consisting of dense fibrous tissue and a more superior “hard” stenosis consisting of osteoneogenesis at the level of the frontal sinus ostium. If the FSOT is identifiable, it is often not large enough to accommodate instruments other than small curettes, much less a drill.

Reports of outcomes of drill-out frontal sinusotomy have emphasized the importance of mucosal preservation, particularly the posterior mucosa, and avoiding circumferential mucosal disruption to maximize long-term success.2 The balloon catheter is a tool used in endoscopic sinus surgery whose role continues to evolve, but one property of the balloon that has received much attention is its ability to preserve mucosa. We have thus found the balloon to be useful in the situation of stenosis described above. The following discussion will illustrate revision frontal sinusotomy using a stepwise technique that first dilates the FSOT using balloon dilation to address the soft stenosis. This maneuver creates sufficient space to both insert and fully visualize the action of an angled drill to address the hard stenosis.

SURGICAL TECHNIQUE AND DISCUSSION

Nasal endoscopy and computed tomographic (CT) scan of the sinuses are necessary for proper patient selection for this procedure. Nasal endoscopy often demonstrates inflammation with a variable degree of scar tissue obstructing the FSOT with no clear visualization into the sinus. The CT images of the sinuses shown in Figure 1 demonstrate obstruction of the frontal outflow tract in the axial and sagittal planes due to a combination of soft tissue and bony elements.

Figure 1.

Axial (A) and sagittal (B) computed tomography of the sinus of the left frontal recess demonstrating combination of soft tissue and bony stenosis with opacification of the sinus. The aerated portion superiorly is the contralateral frontal sinus.

Endoscopic ethmoidectomy (typically revision ethmoidectomy) is first performed, if necessary, to clearly visualize the fovea ethmoidalis and lamina papyracea posterior to the frontal outflow tract. Excision of residual uncinate and opening the agger nasi if present is performed to improve anterior and lateral exposure. Computer-assisted image guidance is often useful to identify the general location of the FSOT in the absence of anatomic landmarks, and its utility specifically in frontal sinus procedures is previously described.3 Scar tissue filling the recess precludes placement of a drill to allow removal of the floor of the sinus. Therefore, balloon dilation of the soft stenosis is first performed. We utilize a light-transmitting guide wire whose successful insertion into the target sinus is confirmed by transillumination rather than the previously described fluoroscopic guidance.4 Once the guide wire is confirmed in the correct position by transillumination of the frontal bone, a 7-mm (inflated diameter) × 24-mm (length) deflated balloon is advanced over the guide wire into the sinus to span the frontal ostium. For extremely narrow tracts, a 3-mm (inflated diameter) balloon is available that has less bulk when deflated. The balloon is inflated to 12 times atmospheric pressure and then deflated and removed to complete the initial sinusotomy (Fig. 2). The soft stenosis of the frontal outflow tract is now dilated, which enables clear visualization of the entire drill bit within the inferior aspect of the frontal outflow tract (Fig. 3). The Draf 2B procedure is then completed by drilling the frontal sinus floor and beak. The completed dissection is depicted in Figure 4. If a Draf 3 procedure is planned, balloon dilation might be repeated for the contralateral FSOT, followed by drilling, which would then include the midline frontal beak. Outcomes, including postoperative photos, regarding these procedures have been previously reported.2, 3, 5

Figure 2.

Intraoperative endoscopic view of balloon dilation of left frontal sinus outflow tract. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

Figure 3.

Intraoperative endoscopic view of left frontal sinus outflow tract following balloon dilation. Note that the entire drill bit is visible in the dilated area. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

Figure 4.

Intraoperative endoscopic view following completion of Draf 2B procedure. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

The additional visualization offered by initial balloon dilation makes other instrumentation safer, with the surgeon avoiding relatively blind removal of scar tissue that could result in inadvertent entry into the orbit or skull base. However, in cases involving complete frontal outflow tract obstruction preventing passage of the guide wire initially, we utilize small curettes and seekers to carefully establish the correct pathway until sufficient diameter is achieved to pass the deflated balloon catheter. The surgeon could continue to remove tissue with other instruments, but in our experience this results in increased bleeding, poorer visualization, and greater operative time compared to balloon dilation.

Regarding safety of drilling, Scott et al. performed a systematic review of Draf III procedures and cited a higher risk of cerebrospinal fluid leak with the Draf III compared with the osteoplastic flap approach.6 Theoretically, and certainly not proven with data, lack of clear visualization might contribute to the risk of damaging vital structures. For example, contact of instruments with the posterior frontal table is particularly difficult to appreciate in a two-dimensional view without depth of field. We have illustrated the spatial advantage gained by using the balloon and believe that combined with a detailed understanding of anatomy, this visualization contributes to reducing the risk of damage to the posterior frontal table, orbit, or lateral lamella of the cribriform plate. Previous studies have documented the safety of the balloon catheter dilation technique, including those specific to the frontal sinus.4, 7–9

It is reasonable to anticipate that the balloon would have difficulty in dilating dense scar. Anecdotally, we have observed that the balloon pressure consistently dilates these areas albeit to a lesser extent than for segments of softer scar. In the event that balloon inflation does not achieve dilation of sufficient diameter to insert the drill, standard dissection should continue. If an outflow tract cannot be established, in accordance with the safety issues mentioned above, the surgeon might consider a trephination to identify the FSOT from above.

There are several advantages to initially using the balloon to dilate the frontal outflow tract. We have found that balloon dilation itself is not technically challenging and requires minimal operative time compared with traditional dissection for soft tissue stenosis. Though not directly measured in our cases, the cost of using the balloon might be warranted by a decrease in overall operative time, and further study is required to address this issue. The illuminated tip guide wire provides guidance into the sinus and subsequent initial sinusotomy with a single instrument. The length of the balloon allows for safe dilation above what can be readily visualized with the endoscope or initially accessed with standard instruments. The balloon is also reliable in mucosal preservation and causes relatively minimal trauma. This translates into better hemostasis and better postdilation visualization for further instrumentation, such as the angled drill.

CONCLUSION

We describe the utility of the balloon as a tool for revision frontal sinusotomy to efficiently and safely allow subsequent instrumentation of the frontal outflow tract with larger more aggressive instruments, such as the drill. We have found this to be a safe and effective technique provided proper preoperative patient selection and assessment for limiting factors.

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