INFLATING VALUE Balloon sinuplasty is a step forward in functional endoscopic sinus surgery (FESS), gently opening sinus cavities to allow better drainage and aeration.

Improved patient monitoring, less invasive procedures, higher-quality implants, better visualization and new frontiers in ear surgery are just some of the trends delivering better outcomes and improved patient satisfaction for ENT physicians. Let's take a closer look at some of the breakthroughs that we're delivering to our patients.

1. Nerve-monitoring systems. The monitors available in today's market continue to be updated and improved, letting us be more precise and confident during several types of surgery. Time was when we did salivary gland, ear or thyroid surgery, we had to try to follow the nerve and watch for any twitching on the patient's part. The twitching indicated that we were making contact with a nerve and risking temporary, or even permanent, damage.

The nerves that go to the vocal cords, for example, are very fragile. Bump them too much during thyroid surgery and they may not recover. Other nerves are less fragile, but if, say, I'm dissecting out the facial nerve for a parotidectomy, and I bang too much on the nerve, that's going to cause some post-operative weakness. And naturally, we'd prefer not to see any weakness after surgery.

Monitoring has been shown to decrease the risk of immediate post-operative facial nerve weakness during parotidectomy (osmag.net/Job4ZC) and it's easy to see why. By putting special electrodes on the distribution of the nerves, we know when we're getting close — we hear it on the monitor well before we'd ever see a twitch. The same with thyroid surgery. We use a special endotracheal tube, so we always know when we're getting close to the nerve.

2. Sinus treatments. Minimally invasive functional endoscopic sinus surgery (FESS) revolutionized sinus procedures, and has ultimately become the standard for the current generation of ENT specialists. But we're now finding ways to be even less invasive. Enter balloon sinuplasty, the nasal equivalent of using angioplasty to open blood vessels. Using a guide catheter and a flexible guide wire, we can access the targeted sinus and then advance a balloon catheter into it. We then inflate the balloon to try to open the sinus cavity and allow better drainage and aeration. Since it's a relatively gentle procedure, it doesn't create more scar tissue.

Balloon sinuplasty is also extraordinarily safe, can be done comfortably under local anesthesia and delivers consistent, lasting improvement. We're able to do most of ours on an outpatient basis.

Impregnated stents are another innovation for sinuses. They're made from a net-like material that slowly releases steroids over a period of 6 to 8 weeks and can be used to treat patients with recurrent nasal polyps. They can also help reduce inflammation in patients who have chronic sinusitis, obviating the need for steroid nose sprays, which rely on patient compliance and which simply aren't as effective as having something that exudes the drug. I suspect this is just the beginning, that we'll see this concept advance over time, leading to slow-release antibiotics and other therapies.

Balloon sinuplasty is extraordinarily safe, can be done comfortably under local anesthesia and delivers consistent, lasting improvement.

3. Better implants for laryngoplasty. This is an area that's really evolved in recent years, with manufactures now creating newer and better implants that are ready to go when we need them.

Because the nerve to the left vocal cord reaches down near the arch of the aorta, it's often inadvertently scratched or damaged during thoracic procedures. In other patients, tumors can push on that nerve and create vocal cord paralysis. In either case, patients can end up breathy, because they can't get their vocal cords together. To treat the damaged nerve, we need to stiffen the paralyzed cord so the other vocal cord can hit against it and create a more normal-sounding voice.

We do it by making a little window behind the vocal cord, and inserting an implant. Patients are under mild IV sedation and we have them vocalize for us while we try different sizes, trying to get the ideal voice. We used to have to make our own implants, but having ready-made implants of various sizes makes it possible to get the desired outcome much more quickly.

ON SCREEN Image-guided systems allow for more precise navigation during surgery.

4. Improved visualization. Between the advent of high-definition cameras and monitors, more versatile and more ergonomic microscopes, and image-guided surgery, we've come a long way. And I'm looking forward to the next steps.

Currently, we're doing image-guided sinus surgery by using a disc that has CT images already loaded onto it. By putting a tracker on the patient, we're able to see exactly where we are in relation to those images. The only drawback is it's not real time. Real-time scans, which are being used more and more in neurosurgery and other disciplines, would help us see whether tissue or organs have shifted during surgery, as well as making it possible to spot bleeding, clots or other complications.

As manufacturers continue to refine the technology, I think the day is coming when we'll be able to have a small scanner in the OR that lets us perform image-guided surgery in real time. Having that capability might be especially useful for complicated ear, skull base and sinus surgeries. And while ultimately, I think real-time imaging will be valuable for both inpatient and outpatient procedures, for smaller outpatient facilities, the feasibility is likely to boil down to when — or whether — the scanners can be acquired at a reasonable price.

A RESTING DEVELOPMENT THN Sleep Therapy is an implanted device designed to keep the airway open during sleep.

TARGETED HYPOGLOSSAL NEUROSTIMULATION
New Procedure May Conquer Sleep Apnea

What millions of people wouldn't give for a good night's sleep. Conservative estimates are that at least 1 in 50 women and at least 1 in 25 men fight a beleaguering battle with obstructive sleep apnea. And the numbers are increasing as the incidence of obesity grows. Various surgical procedures can help, but there are few guarantees, and CPAP machines can be both cumbersome and challenging.

There may soon be an alternative: an implantable device that keeps airways open while OSA patients sleep by delivering mild electrical signals to the hypoglossal nerve, which controls the key muscles of the tongue. The stimulation helps keep the tongue from relaxing and blocking the airway.

The technique is called targeted hypoglossal neurostimulation. It involves implanting a matchbook-size rechargeable pulse generator called the THN Sleep Therapy System near the collarbone and a multi-electrode lead in the upper neck. The procedure takes about an hour. The "pacemaker for the tongue" is turned on at bedtime with a handheld remote, and turned off when the patient awakens. There are no masks or tubes, and patients say they quickly get used to the device, reporting little or no discomfort.

FDA-approved clinical trials are ongoing, and an initial study (osmag.net/u3DGMj) showed promise. Thirteen of 14 patients were successfully implanted with the device, and after 12 months, their AHI — an index used to measure the severity of sleep apnea — was reduced by 53%. The study subjects also had better oxygen saturation, improved arousal and less daytime sleepiness.

— Jim Burger

5. Promising treatments for ear infections. We're pleased that we've been asked to participate in a clinical trial. Just as ophthalmologists are buzzing about the potential of one-drop and dropless treatments for cataracts, we're intrigued by a similar prospect having to do with ear infections. The product in question is a gel that delivers a sustained-release form of the antibiotic ciprofloxacin in pediatric patients undergoing tympanostomy tube placement surgery. Once the ear is completely drained, instead of putting the patient on antibiotic drops for a week, the new product we're helping to test is embedded inside the ear, where it slowly releases the medication for a week or so, completely eliminating the need for post-op antibiotic drops. OSM