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American Journal of OtolaryngologyHead and Neck Medicine and Surgery 32 (2011) 304 307
www.elsevier.com/locate/amjoto

A balloon dilatation technique for the treatment of intramaxillary lesions

using a Foley catheter in chronic maxillary sinusitis
Chan Hum Park, MD, PhDa,b,, Hyung Seob Kim, MDa , Jun Ho Lee, MDa ,
Seok Min Hong, MD, PhDa , Seung Kyun Kim, MDa , Young Gil Ko, MDa ,
Ok Joo Lee, PhDb , Tae Hee Kangc
a
Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Hallym University, Chuncheon, South Korea
b
Facial Skeleton Bio Institute, Hallym University, Chuncheon, South Korea
c
Korea Basic Science Institue Chuncheon Center, Chuncheon, South Korea
Received 23 August 2009

Abstract Background: In chronic maxillary sinusitis, pathologic mucosas of the anterior and lateral walls of
the maxillary sinus are difficult to remove. Trocar insertion to the canine fossa is the most commonly
used procedure. In the present work, we report a method involving a balloon dilatation technique for
treatment of intramaxillary lesions using a Foley catheter in chronic maxillary sinusitis and the
outcomes of this approach.
Methods: Records of 34 patients with intramaxillary sinus lesions who underwent endoscopic sinus
surgery were analyzed. After widening the natural ostium, a 10F Foley catheter was inserted through
the widening ostium into the maxillary sinus. The intramaxillary lesion was removed by repeated
balloon inflation and deflation of the Foley catheter. The patients were followed-up for at least 6
months after the surgery.
Results: There were no significant intraoperative or postoperative complications. We found that the
postoperative symptoms and resolution of the lesions in comparison to classic functional endoscopic
sinus surgery were not different in authors' experiences.
Conclusion: The balloon dilatation technique using a Foley catheter is a minimally invasive
and effective technique that is not associated with major complications in cases of intra-
maxillary lesions.
Crown Copyright 2011 Published by Elsevier Inc. All rights reserved.

1. Introduction invasiveness and maximum preservation of normal tissue and

Endoscopic sinus surgery (ESS) has become the
standard treatment for patients with sinusitis that does not
respond to medical management, but ESS has variable
success rates of 75% to 95% [1-3]. One of the hallmarks of
ESS has been the continued introduction of innovative
instruments underscored by the common goals of minimal
This work was supported by a grant (no. PJ007170201005) from the
BioGreen21 Program, Rural Development Administration, Republic of Korea.
Corresponding author. Department of OtorhinolaryngologyHead and
Neck Surgery, Chuncheon Sacred Heart Hospital, Facial Skeleton Bio Institute,
School of Medicine, Hallym University, #153, Kyo-Dong, Chuncheon,
Kangwon, South Korea. Tel.: +82 33 240 5181; fax: +82 33 241 2909.
E-mail address: hlpch@paran.com (C.H. Park).
0196-0709/$ see front matter. Crown Copyright 2011 Published by Elsevier Inc. All rights reserved.
doi:10.1016/j.amjoto.2010.07.001
mucosa [4]. ESS has proven to be a minimally invasive
surgical choice. In chronic maxillary sinusitis, ESS is used to
widen the natural ostium and remove pathologic lesions.
However, pathologic mucosas of the anterior and lateral walls
of the maxillary sinus are difficult to remove. Consequently,
trocar insertion to the canine fossa is commonly performed.
In the present work, we describe a new balloon dilatation
technique for removing the chronic inflammatory lesion in
chronic maxillary sinusitis.
2. Materials and methods
A retrospective analysis of the records of 34 patients with
chronic maxillary sinusitis who underwent the balloon
 C.H. Park et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 32 (2011) 304307 305

Fig. 1. Preoperative and postoperative CT score based on the maxillary sinus. (A) CT score 1 (mucosal thickness in the left maxillary sinus). (B) CT score 2 (half
soft tissue filling intensity in the right maxillary sinus). (C) CT score 3 (total soft tissue filling intensity).

dilatation technique using a Foley catheter balloon was
performed between February 2007 and March 2008 at
Chuncheon Sacred Heart Hospital (Kangwon, Korea). All
patients had a diagnosis of chronic maxillary sinusitis that
had not responded to medical management and had not
undergone ESS. The exclusion criteria consisted of previous
sinus surgery, lesions located in the frontal sinus, sphenoid
sinus or posterior ethmoid cells, and the fungal sinusitis. All
patients had maxillary sinus or maxillary sinus with haziness
of anterior ethmoid cells on 3-mm paranasal computed
tomographic (CT) scan findings. We performed the
evaluation of preoperative and postoperative CT score

Fig. 2. Intraoperative findings. (A) Using upward forceps, Foley catheter was inserted into nasal cavity in the direction toward maxillary sinus. (B) A 10F Foley
catheter was inserted through the natural ostium into the maxillary sinus. (CE) The end of catheter was positioned on edematous mucosas of the anterolateral
wall of the maxillary sinus. For balloon inflation, about 10 to 20 cm3 of normal saline was injected into the Foley catheter. By balloon inflation, the pathologic
mucosa was ruptured and the discharge drained away through the natural ostium. (F) After inflating the balloon, most edematous mucosas ruptured and squeezed
in the maxillary sinus, finally. White arrow indicates balloon; black arrow, the ruptured pathologic mucosa.
306 C.H. Park et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 32 (2011) 304307

based on the maxillary sinus as follows: CT score 0, no
evidence of sinusitis; CT score 1, mucosal filling intensity;
CT score 2, half soft tissue filling intensity; and CT score 3,
total soft tissue filling intensity (Fig. 1AC). And we
compared patients' subjective symptoms between preoper-
ative and postoperative symptoms at least 6 months after
the surgery.
2.1. Operative techniques
The surgery was performed under general anesthesia. A
rigid telescope with a 4-mm diameter at 0 or 30 was used.
The surgical procedure of the endoscopic approach was done
while observing a video monitor of the nasal surgical
findings. After topical and infiltration anesthesia, the
uncinate process was resected. The natural ostium was
widened using backbiting forceps or microdebrider about a
diameter of 1.5 to 2 cm, and a 10F Foley catheter was inserted
through the widening ostium into the maxillary sinus using
the upward forceps (Fig. 2A and B). The balloon was
positioned on edematous mucosas of the anterolateral wall in
the maxillary sinus, and about 10 to 20 cm3 of the normal
saline was injected into the Foley catheter under endoscopic
guidance for balloon inflation (Fig. 2C and D). The
pathologic edematous or polypoid mucosa was ruptured by
the balloon inflation, and its contents and discharge pushed
through the natural ostium (Fig. 2D and E). After balloon
deflation, we examined the remnant edematous or polypoid
mucosa under endoscopic guidance. The inflation was
performed repeatedly after repositioning the balloon at the
remnant lesion. We could find the improved pathologic
mucosal lesion and remove the remnant of squeezed
pathologic mucosa by using the endoscopic forceps or
microdebrider (Fig. 2F).
3. Results
The mean age of our patients was 30.8 years. The sex
distribution was 19 male and 15 female patients. The chief
complaints on hospitalization were nasal obstruction (28/34,
82.3%), rhinorrhea (10/34, 29.4%), posterior nasal drip (9/
34, 26.4%), and premaxillary tenderness (4/34, 11.7%). The
only symptom reported by patients 3 months postsurgery
was nasal obstruction (2/34, 5.8%). The other symptoms
were completely resolved. The range of preoperative CT
score was 1 to 3 points with a mean of 2.3 0.1 points. The
postoperative CT score (1.2 0.2 points) of all patients
improved. There is a statistical significance between each
group (P = .05). Most of the pathologic mucosas in the

Fig. 3. Computer tomographic and endoscopic findings. (A) Preoperative CT shows the mucosal thickness in the right maxillary sinus, and intraoperative
endoscopic findings shows the edematous pathologic mucosa in the maxillary sinus. (B) Six months after surgery, the right maxillary sinusitis was resolved
completely at postoperative CT. Pathologic mucosa was not seen in the maxillary sinus.
 C.H. Park et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 32 (2011) 304307
maxillary sinus were resolved. There were no significant
intraoperative or postoperative complications (Fig. 3).
4. Discussion
In the past, the purpose of ESS was to widen the natural
ostium, allowing the surgeon to remove pathologic lesions
of the ethmoid cells and frontal recess because these sites
permitted easier removal than other sites [5]. In the case of
maxillary sinusitis, however, surgeons had a bias toward
more conservative management and widened the natural
ostium and waited for spontaneous recovery or medical
management of the pathologic mucosa; but some patho-
logic mucosas were irreversible because of decreased
mucociliary function and fluid retention. These patients
continued to experience symptoms such as posterior nasal
drip and nasal discharge [6,7]. Surgeons began using
curved forceps or a malleable suction tip to remove
pathologic lesions of the maxillary sinus, but the lesion
removal was often insufficient. The recent development of
endoscopy and use of a debrider, however, made it easy to
completely remove lesions; but pathologic lesions of the
lateral and anterior walls of the maxillary sinus could not
be removed.
Trocar insertion to the canine fossa is the most common
approach for lateral and anterior wall lesions, but this
technique has some complications, such as facial swelling
and numbness. We tried a new method using a Foley
catheter, and this approach was effective in removing these
lesions. Foley catheter balloons are approved by the food and
drug administration and used worldwide. We identified a
new surgical method using a common Foley catheter. One
advantage of this method is that the cost of Foley catheter is
much cheaper than other surgical instruments. In addition,
little normal mucosa is lost when the pathologic mucosa
ruptures because balloon inflation is occurring in the
307
maxillary sinus. This is less invasive than the canine fossa
approach and is easier to do.
If ESS is considered minimally invasive surgery com-
pared with the Caldwell-Luc procedure, then the balloon
dilatation technique may be considered a microminimally
invasive surgery achieving the aims of ESS. The ability to
open the paranasal sinus ostia without injury to the
surrounding mucosa is beneficial, and experienced sinus
surgeons will appreciate having an additional technique that
is less traumatic.
We have described a technique for functional surgery on
the paranasal sinus that is safe, involves less or no bleeding,
causes minimal mucosal damage, and consequently requires
further investigation.
5. Conclusion
A balloon dilatation technique using a Foley catheter for
the treatment of intramaxillary lesions was found to be
minimally invasive, effective, and not associated with major
complications.
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