Nasonex Sinus Implant for Chronic Sinusitis

The FDA on August 15, 2011 approved of a novel dissolvable sinus implant that slowly releases mometasone furoate steroid (same active ingredient as Nasonex steroid nasal spray) directly onto the sinus mucosa.

The spring-like implant is placed at the time of sinus surgery and automatically expands and conforms to the sinus cavity regardless of size and shape.

The theory is that by continuously delivering a low dose steroid directly to the sinus cavity, sinus inflammation will decrease and risk of scarring will decrease resulting in an overall decrease in chronic sinusitis for the patient after sinus surgery.

This is a GREAT idea and studies have born out its effectiveness. Hopefully other drug-eluting dissolvable stents like this will be developed in the future!

Developed by Intersect ENT, the implant is called "Propel."

Read about the FDA approval here.

References:
Safety and efficacy of a novel bioabsorbable, steroid eluting sinus stent. INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY. 2011;1(1):23-32.

Advances in the Surgical Management of Chronic Sinusitis and Nasal Polyps. CURRENT ALLERGY AND ASTHMA REPORTS. Published online 08 February 2011

Controlled steroid delivery via bioabsorbable stent: Safety and performance in a rabbit model. AMERICAL JOURNAL OF RHINOLOGY & ALLERGY. November–December 2009, Vol. 23, No. 6.

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New Video on Endoscopic Vocal Cord Mass Injection & Bronchoscopy Without Sedation

We have produced a new video demonstrating how vocal cord masses can be injected with medications (like steroids) under endoscopic guidance without the need for any sedation. This video also includes bronchoscopy that was performed at the same time (also without any sedation).

Check out the video here!

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Video of Endoscopic Salivary Stone Removal (Sialendoscopy)

The Doctors TV show actually produced a great (and accurate) segment on a relatively new procedure called sialendoscopy. This procedure allows a surgeon to remove a stone that may be blocking your spit gland from draining saliva into the mouth. This is analogous to a kidney stone which blocks urine from draining from the kidney into the bladder resulting in painful swelling of the kidney (causing flank pain).

How does a person know if they have a salivary gland blockage due to a stone? There is a painful swelling located right in front and/or below the ear if the parotid gland is affected, or under the jawbone if the submandibular gland is blocked.

If the blockage persists long enough, it may lead to an infection of the gland itself (sialadenitis).

Traditionally, if the stone doesn't pass on its own with conservative measures, stone removal required surgical removal of the entire gland or making an incision and removing the stone like it's a tumor mass.

Watch the video of this procedure being performed as shown on The Doctors here.

At this time, the only local surgeon I am aware of who offers this unique procedure in the mid-Atlantic region is Dr. Arjun Joshi.

Dr. Arjun Joshi (George Washington University Hospital in Washington DC)
2021 K St NW, Ste 206
Washington, DC 20006
Office Number: 202-741-3250
www.dcheadandneck.com

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Zenker's Diverticulum Endoscopic Treatment Confusion

Having treated many patients with Zenker's Diverticulum using the endoscopic approach, I've had many confused patients ask me how the diverticulum is treated if it is not removed.

For those unfamiliar with this disorder, click here for more information.

The basic concept of treating this rare disorder is that there is a common wall that divides the esophagus from the diverticulum pouch. This common wall is endoscopically divided such that the pouch now becomes the new back wall of the esophagus. So when the patient swallows, food/liquids can no longer get "trapped" causing symptoms.

Still confused? Here are some picture illustrations...

When endoscopically exposed, the pouch is denoted by the arrow.

When looking through the scope placed into the mouth down into the throat, there is a common wall that is between the pouch (blue arrow) and esophagus (green arrow).

Endoscopically, whether using a stapler or laser, this wall is divided down the middle. This picture shown below is when a stapler is used.

Here is the side view before and after common wall division:

After the procedure, any food/liquid substances that are swallowed can't be trapped in the pouch. Therefore, even though nothing is surgically removed, the patient's swallowing symptoms completely disappear.

Hopefully, this explanation helps clear up any confusion of what exactly happens!

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New Video Produced on How/What a Normal Swallow Looks Like

Our office has produced a new video on what/how a normal swallow looks like from BOTH an x-ray as well as endoscopic view. In order to best illustrate the swallowing mechanism, a modified barium swallow test is shown. The video has been uploaded to our YouTube channel and can be watched here.

Watch the video below as well as the slow motion action of what the epiglottis does from the inside during a swallow!

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New Video On Balloon Sinuplasty for Chronic Sinusitis Uploaded

A new video describing balloon sinuplasty has been uploaded on our YouTube channel. Balloon sinuplasty is a relatively new minimally invasive sinus surgery technique to open up diseased sinus cavities without removing mucosa or bone.

In essence, the technique involves threading a tiny guidewire to first identify the sinus opening and than acts as a guide for the balloon catheter. Once the balloon is positioned at the opening of the sinus cavity, it is inflated thereby enlarging the sinus cavity opening.

Watch this sinus surgery technique below or on our YouTube channel here.



Here is an animation of what exactly is going on:

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New Surgical Approach to Treat Small Zenker's Diverticulum

In the January 2010 edition of Laryngoscope, an interesting paper entitled "Transoral resection of short segment Zenker's diverticulum and cricopharyngeal myotomy: an alternative minimally invasive approach" was published on a new endoscopic approach to surgically treat very small Zenker's Diverticulum. This endoscopic approach is also able to treat cricopharyngeal spasms/hypertrophy.

Just as for the Endoscopic Staple Diverticulostomy (ESD), the most common endoscopic approach to treat Zenker's diverticulum, a Weerda laryngoscope is used to visualize the pouch. However, instead of using a stapler to treat the pouch, the pouch is everted into the esophagus and the pouch excised. The cricopharyngeal muscle is than incised under the microscope as well as endoscopically before the mucosal incision is closed using sutures.

The authors have called this procedure Trans-Oral Resection of Diverticula (TORD). When used to treat the cricopharyngeal muscle only, the procedure is called Trans-Oral Cricopharyngeal Myotomy (TOCPM).

Patients generally go home after 24 hours.

Read more about this research here.

No... our office does not offer these procedures at this time. Only the ESD approach.

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Recurrent Chronic Sinusitis Often Due to Allergies

A 2009 research paper lends credence that allergies may be a VERY important player in patients who suffer from recurrent sinus infections. Such patients will improve with antibiotics only to have their sinus infection symptoms recur shortly after completing the antibiotics.

The research described how allergy exposure to patients resulted in a rapid and radiographically significant response of sinus disease including mucosal thickening and/or opacification. How fast? Within 60 MINUTES!!!

These findings lend support that should patients suffer from recurrent sinus infections that do not clear readily with antibiotics alone should be investigated for allergies. Furthermore, allergy testing and management should be performed in all patients considering sinus surgery. Why? Because if allergies are playing a role, opening up the sinuses via surgery will only exacerbate allergy triggered sinus infections.

What is our office protocol for evaluating patients with chronic sinus infections?

1) History supportive of recurrent sinus infections in spite of antibiotics as well as trial of allergy medications
2) CT Sinus documenting presence of sinus disease for surgical consideration as well as elucidating whether true sinus problems are causing the symptoms
3) Allergy testing (Our office performs immunoCAP blood testing instead of skin prick testing)

If allergy testing is positive, aggressive allergy control is the first step prior to (or at the very least concurrent with) any other intervention including sinus surgery.


Reference:
Diagnostic Value of Nasal Allergen Challenge Combined With Radiography and Ultrasonogrphy in Chronic Maxillary Disease. Arch Otolaryngol Head Neck Surg. 2009 Dec;135(12):1246-55. doi: 10.1001/archoto.2009.189.

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