Endoscopic Surgery Versus Balloon Sinuplasty in Chronic Rhinosinusitis

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Pirkanmaa Hospital District, M building, Main auditorium, address: Teiskontie 35


Doctoral defence of Lic. Med. Argyro Bizaki

Endoscopic Surgery Versus Balloon Sinuplasty in Chronic Rhinosinusitis

The field of science of the dissertation is Otorhinolaryngology.

The opponent is professor Elina Toskala (Temple University, USA). Professor Markus Rautiainen acts as the custos.

The language of the dissertation defence is English.

Endoscopic Surgery Versus Balloon Sinuplasty in Chronic Rhinosinusitis

Rhinosinusitis (RS) is a common medical condition with substantial symptoms and a remarkable impact on the quality of life (QoL). The term RS is defined as the concurrent infectious and inflammatory processes that affect the nasal passages and the surrounding paranasal sinuses. Infection, mucosal hyperactivity and anatomical variation all contribute to some extent to the pathophysiology of RS. Chronic rhinosinusitis (CRS) is an inflammatory condition of the nasal passage and paranasal sinuses lasting for 12 weeks or longer. A key point of CRS is the persistent inflammation of the nasal and paranasal cavities. Symptoms of CRS vary in severity and prevalence. Surgery is reserved for patients who are refractory to medical treatment.

This aim of this thesis is to study the effects of balloon sinuplasty (BSP) and endoscopic sinus surgery (ESS) on the quality of life (QoL) of patients diagnosed with CRS. In a prospective randomized non blinded controlled trial, the clinical outcome and impact of both BSP and ESS treatment were assessed and compared separately. Acoustic rhinometry and rhinomanometry were used to assess nasal airway patency. Mucociliary clearance (MCC) was measured with an endoscope and gamma camera after 0.03 ml of saccharine, methylene-blue dye and human albumin labelled with Tc99m was introduced to the bottom of maxillary sinuses. Further, the pathology of the upper airway mucosa and the expression of matrix metalloproteinase-9 (MMP-9) protein was studied. In addition, changes in histopathology after treatment were evaluated and compared.

Adult patients with symptomatic isolated CRS or recurrent acute rhinosinusitis (RAR) without severe findings in the sinuses, as documented in a sinus cone beam computer tomography (CBCT) scan and clinical examination, were randomized in 2 groups: ESS and BSP. The main variables in this study were the Sinonasal Outcome Test-22 (SNOT 22), the rhino tests (acoustic rhinometry and rhinomanometry), MCC and the histopathology of the nasal mucosa. These parameters were analysed preoperatively and postoperatively after 3, 6 and 12 months. The study was carried out at the Department of Otolaryngology, Tampere University Hospital, Finland.

There was not only a subjective improvement in symptoms after surgery but also an objective improvement in the QoL of our patients seen as a decrease in the total SNOT 22 score (P < 0.05). There were no significant differences found between the ESS and BSP groups (P > 0.05). Based on rhinomanometry results, nasal airway resistance (NAR) decreased after treatment. With regard to adverse effects, BSP was noticeably associated with a lower risk of synechia. Neither of the treatment methods had any effect on MCC. As assessed by saccharine test, smoking was associated with a worse mucociliary transport rate. Methylene blue test results were correlated to the results from the saccharine test and Tc99m-labeled tracer technique separately.

Histopathological analysis of the nasal mucosa before treatment showed increased thickness of epithelium, absence of cilia, metaplastic changes of epithelium, hyperplasia of the mucosal glands, angiogenesis, remodelling of epithelium, thickened lamina propria (LP) and infiltration of the epithelium and mucosa by inflammatory cells.

Allergy was correlated with the hyperplasia of goblet cells and absence of cilia was associated with worse QoL. The number of inflammatory and goblet cells were linearly correlated preoperatively and after treatment. Amelioration of treatment was observed in both treatment groups. A strong positive association was found between the expression of matrix metalloproteinase-9 (MMP-9) in epithelium and the number of inflammatory cells in the nasal epithelium and mucosa. Hypertrophy of the mucosal glands, hyperplasia of blood vessels and mucosal edema were reduced after both treatments. These histopathological changes were more remarkable in the uncinectomy group. BSP was correlated with a higher number of inflammatory cells at 6 months after treatment (P = 0.05).

Both ESS and BSP had a positive effect on the QoL of patients and decreased NAR. Both surgical techniques seemed to be equally effective in the treatment of CRS. The less traumatic nature of BSP most likely explains the lower risk of developing adhesions postoperatively. Both techniques affected positively on mucosal inflammation but failed to recover mucociliary function.


The dissertation is published in the publication series of Acta Universitatis Tamperensis; 2203, Tampere University Press, Tampere 2016. ISBN  978-952-03-0212-2, ISSN 1455-1616. The dissertation is also published in the e-series Acta Electronica Universitatis Tamperensis; 1703, Tampere University Press 2016. ISBN  978-952-03-0213-9, ISSN 1456-954X.

The dissertation can be ordered at: Juvenes e-bookstore or by e-mail: verkkokauppa@juvenesprint.fi.

Additional information

Argyro Bizaki, Tel. 044 308 3282, arbizaki@gmail.com