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What's New in Chronic Sinusitis Treatment
Clear your patients' heads with balloon sinuplasty, image-guided navigation and steroid-eluting stents.
Kendal Gapinski
Publish Date: March 31, 2015   |  Tags:   ENT
Natan Scher, MD, performs sinus surgery SINUS SURGERY Natan Scher, MD, performs sinus surgery at Ingalls Memorial Hospital in Harvey, Ill.

After rounds of medications fail to clear patients' stuffy, congested heads, they want a fix and they want it fast. While there is no cure for chronic sinusitis, new treatment options and surgical technologies are providing easier and more effective relief to patients. "The treatments are aimed at draining the sinuses while being painless to the patient and as long-lasting as they can be, so patients don't have frequent recurrences," says Martin L. Hopp, MD, PhD, medical director of the Cedars-Sinai Sinus Center in Los Angeles.

With technology like drug-eluting stents, balloon sinuplasty and ENT navigation, your docs have more options than ever to treat a wider spectrum of sinusitis sufferers. "We have new tools to reduce the amount of bleeding, and we have new methods to reduce the amount of pain," says Natan Scher, MD, an otolaryngologist at Ingalls Health System in Harvey, Ill. "We also have new implants and some other technical methods that all help to improve outcomes."

Balloon sinuplasty made simple
While balloon sinuplasty has been around for almost a decade, it is now less reliant on general anesthesia and is shifting from mainly hospital settings to ambulatory surgery centers or offices. It's also one of the largest growing treatments for sinusitis, thanks to its quick recovery period and convenience for patients. "It has revolutionized sinusitis treatment," says Dr. Hopp.

Increasingly being done only under local anesthesia, balloon sinuplasty is evolving to work well in high-turnover settings, says Dr. Hopp. In the updated procedure, a local anesthetic is injected into the sinus and patients remain awake for the procedure, allowing for a quicker recovery. The balloon catheter is inserted into the inflamed sinus and inflated to expand and restructure the sinus opening. Saline is then sprayed into the inflamed sinus to flush out pus and mucus, and the system is removed, allowing the sinus to drain.

image-guided navigation A NOSE ROADMAP Image-guided navigation systems let surgeons use a "map" to find their way during sinus surgery.

Its minimally invasive qualities attract both patients and doctors. It's much less traumatic than endoscopic surgery, the doctors say, with patients able to return to normal activities within 2 days. With about 33 million reported cases of sinusitis every year, many patients are drawn to the quick fix. "A lot of patients don't want to be on antibiotics if there's a minimally invasive surgical option," says Andrew Lane, MD, director of the Johns Hopkins Sinus Center in Baltimore, Md. The procedure also comes with a decent reimbursement, he says, typically around $2,000 for ASCs and office-based facilities.

That doesn't mean there aren't downsides. Dr. Scher notes that balloon sinuplasty can usually only help patients with mild to moderate chronic sinusitis, and may only be effective in the frontal sinuses. It also doesn't offer relief for those who suffer from nasal polyps, thicker pus or a severe infection, he says. "Office-based balloon sinuplasty is in its infancy still," says Dr. Scher. "It's not clear if it's going to work for the majority of the patients or for a selective group."

Breathe easier with ENT navigation
Many surgeons use ENT navigation only for difficult or severe FESS (fundamental endoscopic sinus surgery) cases, but Dr. Hopp says that the ability to have a "map" of anatomical features while restructuring sinus openings in surgery can help both your docs and patients breathe easier. "There are different attitudes towards its use," he says. "It's clearly been helpful in more advanced cases, and in primary cases there's debate that it may or may not be helpful. I have my own opinion, which is that it's helpful for everything."

The newest image-guided systems help doctors navigate through the nose using a 3D map that's created with the help of CT scans. Manufacturers say these real-time 3D images help your surgeons avoid orbital injuries, entry into the brain and the carotid artery. Dr. Lane notes that 3D navigation is becoming more popular, though it "still hasn't caught on," as facilities tend to hold on to older technology.

If you're in need of an update, know that there are more benefits to buying a new system than just 3D imaging. ENT navigation systems are now smaller, more accurate and more portable, says Dr. Hopp. He notes that some of the newer models can even be as small as a laptop, making them "ideal for outpatient facilities," since they're a less expensive capital investment. Other features, like touchscreens, wireless technology, simple setups and "intuitive" software, are also appealing, says Dr. Lane.

The 2 main types of ENT navigation systems — electromagnetic and optical (infrared) — each have their benefits and drawbacks, says Dr. Lane. He suggests involving your doctors in any purchasing decisions, since the choice often comes down to physician preference. Also look at the cost per case, since that can vary depending on the model and how many instruments a surgeon uses. The newest navigation systems typically cost $100,000 to $200,000, with disposable costs ranging from $50 up to $400 per case.

Improved healing after endoscopic surgery
FESS has been the traditional go-to procedure for more moderate-to-severe cases of chronic sinusitis, says Dr. Lane. While the techniques have largely remained the same, post-op care and surgical tool updates have made the procedure easier for docs and less painful for patients.

One of the biggest advancements has been surgeons' ability to reduce bleeding of the sinuses during surgery, which improves healing and limits painful post-op nasal packing. "That's where patients really suffer," says Dr. Scher.

There are several new practices and tools that improve patients' recovery after FESS, says Dr. Scher. Smaller tissue cutting tools that include hemostatic elements like laser or radiofrequency — as well as the introduction of absorbable hemostatic pastes and dissolvable nasal packing — limit bleeding. These products and devices reduce packing, which is removed a few days after surgery in a procedure that is uncomfortable for patients and time-consuming for surgeons.

Additionally, instruments such as small microdebriders — traditionally used in orthopedic cases — that cut tissue while providing suction to remove tissue and polyps claim to provide better mucosal preservation and improve healing, says Dr. Lane, although clinical research is limited. Many of the new surgical tools becoming available are cumbersome, he adds, though they are improving.

smaller ENT systems

Post-op care models are evolving too. While eliminating or reducing packing is one way to stop discomfort, another easy and cost-effective way to facilitate healing is to irrigate the sinuses. According to Dr. Lane, patients can use irrigation "squeeze bottles" — found in many drugstores — filled with a solution of saline, steroids and/or antibiotics after surgery. The irrigation helps reduce inflammation and keep the sinuses moist, keeping your patients more comfortable. "A lot of patients come back and say they had no pain at all," says Dr. Lane. "Generally speaking, the nose tolerates surgery pretty well."

OSMOSIS OPTION
For a Truly Minimally Invasive Technique, Try Osmosis

Vent-Os Sinus Dilation System\ LOW IMPACT The Vent-Os Sinus Dilation System by SinuSys is a less invasive way to clear clogged sinuses.

Balloon sinuplasty has been the gold standard for minimally invasive sinusitis treatment, but a new technology promises even less trauma while opening up the sinuses.

The new treatment, Vent-Os Sinus Dilation System by SinuSys, uses osmosis as part of a 2-step process to drain the sinuses. A clinician first inserts a device that is similar to "a small dried-out sponge" into the opening of the frontal sinuses, says Martin L. Hopp, MD, PhD, medical director of the Cedars-Sinai Sinus Center in Los Angeles. The device, the size of a grain of rice, is then left in the sinus opening for 60 minutes. It self-expands as it soaks up the pus clogging the sinuses, helping to open the passageways and drain the sinus. Patients can sit in the waiting room between insertion and removal and it only requires the use of local anesthesia. Plus, the cost compares to the more common balloon sinuplasty, says Dr. Hopp.

He notes that while it doesn't work for more moderate-to-severe cases, the non-invasive procedure can be great for those who suffer from sinusitis but don't want to undergo rounds of antibiotics or steroids. "It's a non-traumatic and painless way to open the sinus," says Dr. Hopp.

— Kendal Gapinski

Steroid-eluting stents limit inflammation
There is also now a more efficient way to get steroids into the sinuses after surgery that the doctors say is the next big thing: steroid-eluting stents.

Dr. Hopp says that the steroid-impregnated implants help stop the formation of polyps and reduce inflammation after FESS. Dr. Scher says after enlarging the ethmoid sinus opening during surgery, he places the dissolvable steroid-eluting stent into the sinus passageway. The stent is made of a net-like material that is built like a spring, so it props open the passageway while releasing mometasone furoate, a corticoid steroid. The stent can last for more than 30 days before it dissolves. So far, Dr. Scher says he's happy with its outcomes. "The slow release of anti-inflammatory medication produces very impressive results," he says.

The stents could help prevent recurrences of polyp formation and reduce inflammation in serious cases of sinusitis and may offer a better solution than manual irrigation, surgeons say. Still, they add an additional cost to each case —about $700 per implant, which is not covered by many insurers — and can currently be used only in the ethmoid sinuses. There's also limited clinical research showing their advantages, says Dr. Lane. "It has some benefit of improved healing and reducing the swelling, but after it's dissolved then you must transition from that to something like saline rinses," says Dr. Lane.

The hope, the doctors say, is that these drug-eluting stents are just the first wave of treatments. Currently there is only 1 manufacturer selling the implants, but others with more diverse approaches are on the way, says Dr. Lane. "I do think there's going to be a continued evolution of implants," he says. "Right now, there's only steroids, but in the future it might be different shapes, or they might be available for different sinuses, or offer other drugs."

Buying into the idea
While sinusitis treatment and surgery is thought to typically have a rosy reimbursement, the docs say, insurers are less likely to cover some of the latest technologies and treatments. That shouldn't necessarily turn you away from considering these new products, says Dr. Lane, since patients suffering from headaches, fatigue and congestion often seek out facilities that take the extra step to offer improved outcomes. "This surgery is very equipment-heavy," says Dr. Lane. "But most of these technologies end up paying for themselves."

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