Follow Up on "Sinus Relief Now" Book Review by Rocky K., Patient of Dr. Jordan Josephson, the Author

  Article Index 

LASER
The book doesn't explain the tradeoffs of laser vs. traditional cutting instruments.  Before Josephson, I saw an ENT who recommended laser to lightly cauterize the turbinates in order to reduce their tendency to swell when inflamed (the scarification reduces the membrane's elasticity).  Dr  Josephson is not a proponent of laser except in certain cases.  Although a laser is self-cauterizing and therefore reduces bleeding, it causes heat damage to surrounding tissue (more than the damage caused by a cutting instrument) and instrument setup adds time/cost to the procedure.  Only where the decrease in bleeding outweighs these costs is use of a laser justified (e.g. when the patient has many small polyps).  I didn't ask him but I'd imagine that the thermal heat injury would likely cause more damage to mucus-producing goblet cells and mucus-transporting cilia cells than cutting tools.

SINUPLASTY
This book doesn't explain the tradeoffs of sinuplasty® vs. traditional cutting instruments.  Sinuplasty® is a proprietary tool made by Acclarent which uses a thin balloon similar to an angioplasty balloon to open the sinus passages. As in heart vessels, the balloon is placed into position and inflated, then deflated and removed. According to Acclarent's description, this results in permanent widening of the critical areas leading into the sinuses while leaving the nose lining unharmed rather than destructing this lining as occurs in typical sinus surgery.  I would have to imagine that if the pressure applied expands bone than it certainly will crush the membranes and must do some damage to them and the cilia which are so necessary to remove the infection and mucus (mucociliary clearance) which is the whole basis by which the sinuses protect you. When I asked  Dr. Josephson about what the pressure does to the membranes he said that he knew of no studies that showed what the effect of the balloons on the membranes and cilia were.  It turns out that Dr. Josephson is trained in sinuplasty but relies almost exclusively on FESS (endoscopic cutting instruments, as described in his book).  He pointed out that unlike angioplasty, which operates on only soft tissue and requires a stent to hold open the expanded tissue, sinuplasty expands a passageway or sinus by dilating bony openings and pathways--widening one passageway by crushing an adjacent sinus cavity.  He speculates that such pressure fractured cells could result in a problem later such as mucocele formation--the procedure was too recently developed and long term studies were not available.  In addition, while sinuplasty can open up a closed frontal, maxillary, or sphenoid sinus, it cannot open up the labyrinth of the ethmoid sinus.  If the ethmoids are closed, functional FESS may be required in conjunction.

FUNCTIONAL ENDOSCOPIC SINUS SURGERY (FESS)
Josephson doesn't much describe his surgical techniques in this book, which makes it difficult to compare FESS with alternative approaches.  Dr Josephson says Functional Endoscopic Sinus Surgery (FESS) uses microcutting instruments to remove bony partitions and to widen openings into the frontal, maxillary and sphenoid sinus when necessary. I asked how he expands the passages to closed sinus cavities.  He explained that, in my case, he would remove the wall between the passage to a frontal sinus and an adjacent ethmoid sinus cell (rather than crushing the ethmoid cell as in sinuplasty).  This would be more controlled than expanding a balloon (as in sinuplasty) and avoid creating a new closed cell which could become a cyst.  While FESS changes the connectivity of the cavities, it avoids potentially closing off the adjacent cells.  He claims that research shows that mucus transport from the now-opened frontal sinus to the ostiomeatal complex is preserved with this method.  This book should include and expand on these descriptions.  I also asked in what cases the membranes grow back which seems important when polyps are removed from sinus cells, leaving bare bone walls.  He replied that they quickly grow back.  This book should include pointers to research validating this claim.

SINUS ANATOMY
This book describes the sinuses as cavities which clean and humidify inhaled air. However, the diagrams show the sinuses as dead-end spaces off the primary airway connected only by tiny passages.  Why does air travel through them except a small amt via turbulence?  Although I suspect they do indeed clean and humidify inhaled air, it would be helpful to me if the book resolved this seeming contradiction.

CAT SCANS
The book includes a series of diagrams showing an idealized representation of the sinuses and other organs.  I found it very difficult to relate my CT scans to these idealized diagrams even though I'm quite good at 3D visualization.  It would be helpful if this book included a link to an online series of example CAT scans with annotation explaining what's what, how the structures relate to disease symptoms, and (assuming some patents get post-operative CT scans) what the structures look like after surgery.  Josephson told me that he had a CT review in a draft of the book and Penguin Publishers needed to make the book shorter and insisted that he cut it out. Eventually he plans to put it on line.

Written by Rocky K. and republished by permission.