Sinusitis

It is currently thought that certain individuals may have a hyperactive or “revved up” immune system. This predisposes them to have significant inflammation in the sinus lining triggered by certain environmental factors. This can be thought of as “asthma of the nose.” When patients are exposed to these environmental “triggers” a flare-up may occur and patients can experience significant congestion, drainage, and swelling in their mucosa. This can result in facial pain/pressure, headache, and fatigue when the sinuses are obstructed.

The external triggers differ for everyone but may include environmental allergies (pollens, trees, dust, molds, etc.), viral, bacterial, or fungal infections, or even pollution or tobacco smoke. Once a susceptible patient is exposed to an external trigger, a cycle of inflammation begins. Often the resultant swelling and congestion leads to a secondary bacterial infection that further exacerbates the inflammation. Severe, prolonged inflammation can result in nasal polyp formation (see picture on right).

Other causes of sinus obstruction can include trauma or previous surgery. Scarring from prior sinus surgery may lead to blockage of the sinuses. When this happens, a detailed evaluation is needed by a surgeon with extensive experience in revision sinus surgery, as repeated surgery may be needed.

Less common causes of sinusitis include diseases such as cystic fibrosis, Wegener’s granulomatosis, sarcoidosis, and immunodeficiency. These are highly complex cases and usually require the care of a sinus specialist.

Widely open sinuses in patient three months after sinus surgery.

When should a CT scan be obtained?

Once a patient has been treated with medications (generally for a minimum of 4 weeks), a CT scan may be obtained. Doctors can evaluate all sinuses with a screening CT scan, such as the one shown that demonstrates the maxillary and ethmoid sinuses. This will give the doctor an idea of the sinus anatomy that may be contributing to the problem and permits evaluation of areas of the sinuses that are not visible using the endoscope. Most patients with sinusitis respond to the medications and DO NOT require surgery.

When is surgery indicated?

Evaluation and treatment: Patients with sinus symptoms, such as nasal congestion, postnasal drip or headache, should be evaluated by an ENT doctor to determine if their symptoms are coming from sinusitis or another similar condition, such as allergies, migraine headaches or acid reflux. The evaluation and treatment of sinus patients usually involves nasal endoscopy, examining the inside of the nasal passages with a small telescope and treatment with medications for a minimum of 4 weeks. At the end of that timeframe, if symptoms persist, a CT scan may be obtained. This will give the doctor an idea of the sinus anatomy that may be contributing to the problem and permits evaluation of areas of the sinuses that are not visible using the endoscope. The diagnosis of chronic sinusitis must be based upon an assessment by your doctor, as other problems can cause symptoms like those found with sinus disease. Many patients with sinusitis respond the medications and DO NOT require surgery. The MUSC Sinus Center is actively involved in several clinical trials investigating medical treatment of patients with chronic sinusitis.

Surgery is generally needed for the minority of people with chronic sinus problems who do not respond to medical therapy. The diagnosis of chronic sinusitis must be based upon an assessment by your doctor, as other problems can cause symptoms like those found with sinus disease. Most people with sinusitis DO NOT require surgery. Their sinus symptoms can usually be successfully treated medically. This includes antibiotic therapy and other medications, treatment of allergies, and environmental control. The type of medical therapy used is based upon your doctor’s assessment of the cause.

When medications fail to work and persistent disease is seen on the CT, surgery is an option. Surgery may be needed if an infected or inflamed area does not clear with antibiotic therapy or other medications, the symptoms return when antibiotics are stopped, or for other reasons. You should discuss your CT and the need for sinus surgery with your doctor.

Large polyp with surrounding thick secretions indicating active infection.

What is functional endoscopic sinus surgery (FESS)?

One way FESS differs from traditional sinus surgery is that a thin rigid optical telescope, called an endoscope, is used in the nose to view the nasal cavity and sinuses. This technique has revolutionized the surgical treatment of chronic sinusitis. FESS generally eliminates the need for an external incision. The endoscope allows for better visualization and magnification of diseased or problem areas. This endoscopic exam, along with CT scans, may reveal a problem that was not evident before.

Another difference is that FESS focuses on treating the underlying cause of the problem. The ethmoid sinuses are usually opened. This permits direct visualization of the maxillary, frontal, and sphenoid sinuses and diseased or obstructive tissue can be removed if necessary. There is often less removal of normal tissue and surgery can frequently be performed on an outpatient basis without the need for painful packing that was used in the past. Generally, there are not external scars, little swelling, and only mild discomfort.

The goal of FESS is to open the sinuses more widely. Normally the openings to the sinuses are long narrow bony channels covered with mucosa or the lining of the sinuses. If this lining swells from inflammation, the sinuses can become blocked, and an infection can develop. FESS removes some of these thin bony partitions and creates larger openings into the sinuses. After FESS, patients can still develop inflammation from allergies or viruses, but hopefully when the sinus lining swells, the sinus will remain open. This will permit easier treatment of subsequent exacerbations with more rapid resolution and less severe infections.

Powered instrumentation can be useful during FESS to precisely remove polyps and other diseased tissue, while sparing the surrounding normal sinus lining and adjacent structures. The latest generation of hand instruments allows the surgeon to meticulously open the sinuses, while avoiding the “grab and tear” techniques of the past. Once the diseased tissue is removed and the inflammation subsides, the injured sinus lining often returns to a normal state with time.

When is computer-guided surgery used?

Computer-assisted surgical navigation is a relatively new tool used in select cases. These devices provide information on the anatomic location of instruments within the sinuses during surgery and can also be used to perform 3D reconstructions that may be helpful to your surgeon. It is typically indicated for revision cases, nasal polyposis, or skull base tumors where normal surgical landmarks have been removed or altered. As with all equipment, image-guided systems can be wrong from time to time and surgeons cannot rely solely on the technology. They must correlate the image-guided information with their training, experience, and knowledge of the anatomy to avoid complications due to human or technical errors.

Computer guidance during sinus surgery.

When is balloon sinuplasty used?

Balloon sinuplasty is a newer technology that uses balloons to stretch and dilate the openings to some of the sinuses, rather than removing tissue. This may be appropriate for some patients with limited inflammation but is probably not indicated for patients with polyps or scar tissue that must be removed.

What can patients expect after FESS?

Introduction

Most patients will experience significant improvement in their sinus symptoms after surgery. However, it takes time for the body to heal. While some patients may notice improvement immediately following surgery, others may take weeks before they feel a lot better. This depends on several factors including the type and extent of surgery and the patient’s personal experience. Remember, it takes time for the sinuses to fully heal after surgery.

Expectations

Packing: You may or may not have packing in your nose after surgery. If you have packing, it can come in two forms. One is absorbable and will dissolve on its own with time and regular saline irrigations. The other is not absorbable and will be removed by your doctor at a clinic appointment after surgery. Your doctor may also use stents or spacers with corticosteroids on them to help reduce inflammation and swelling after surgery.

Irrigations: The most important thing you can do to help your recovery after surgery is to regularly irrigate your nose and sinuses with saline rinse after surgery. Your doctor will show you how this works. S/he will also tell you when to start (usually within 1 to 2 days after surgery). Gently apply pressure on the rinse bottle while you lean over the sink or shower. You do NOT need to push hard.

Antibiotics: Infection is a common problem in patients with chronic sinusitis. It is also a risk of surgery. Your doctor may administer antibiotics during your surgery or prescribe antibiotics after surgery.

Steroids: One of the underlying causes of chronic sinusitis is inflammation and swelling. To improve healing and treat inflammation, your doctor may prescribe oral steroids, topical steroids, or both. Topical steroids often come in the form of a spray or a medicine placed in saline irrigations.

Pain: Some patients experience minimal amounts of pain after surgery, while others may experience significant pain for several days. Your doctor will discuss an appropriate pain management regimen for after your surgery. S/he may give you a prescription for pain medication. Over-the-counter medications such as Tylenol may also be used.

Bleeding: It is common to see drops of blood or blood-tinged nasal secretions after surgery. Keep your head elevated. Avoid nose blowing. If you feel a sneeze or cough coming, open your mouth and let it out. Avoid lifting heavy objects and strenuous exercise for the first 1-2 weeks after surgery. Also avoid medications that can thin your blood such as aspirin and herbal medications until cleared by your doctor. It is NOT normal to have heavy amounts of bleeding after surgery. If you have bleeding that does not stop after holding nasal pressure for several minutes or you are concerned that you are bleeding too much, call your doctor’s office immediately or go to your local emergency department for further evaluation.

Nasal congestion/obstruction: Some patients may notice improvement in their nasal congestion immediately after surgery. Others may not notice improvement for several days to weeks. Both experiences are normal. After surgery, nasal congestion may be related to many factors including packing, crusting, and normal post-surgery swelling. Be patient, irrigate regularly, and follow up with your doctor. It should get better.

Fatigue: It is common to feel tired in the first days to weeks after surgery. Remember to take it easy while your body is recovering.

Clinic visits after surgery: It is important to see your doctor in clinic after surgery. S/he will look in your nose with an endoscope, remove any crusts that do not flush out with saline irrigations, you may hear this referred to as a “debridement”, and pull out any non-absorbable packing. Additionally, s/he will make sure you are not scarring, that you are healing well, and are on the road to recovery!

Return to work: Plan to take some time off after surgery. Some patients will be ready to go back to work in a matter of days while others will need one to two weeks to recover. This will depend on the extent of surgery, your recovery experience, and the nature of your work. If you have a desk job, you may be able to go back to work before the end of a week but expect to be tired and limit your work demands. If you have a job that demands strenuous labor, you may need to take as much as two weeks off until your body has time to heal. Be patient. If you push yourself too hard and too fast, you may risk slowing the healing process or experiencing bleeding. With time and good post-surgery care, most patients experience significant long-term improvement!

Will endoscopic sinus surgery improve my symptoms?

Most patients who have endoscopic sinus surgery do very well, with significant improvement in their symptoms.

What are the potential complications of endoscopic sinus surgery?

Introduction

Surgery of the nose or sinuses may be offered if medicine such as antibiotics, nose sprays, or steroids do not make a patient better. All types of surgery have risks, including surgery of the nose and sinuses. Patients must be aware of these risks before electing to proceed and weigh the benefits of the procedure against the risks involved. A discussion regarding the risks, benefits and possible alternatives to surgery between the patient and surgeon is strongly encouraged. Some of the more common or more important risks relative to nasal and sinus surgery are discussed below.

Complications of Nasal Surgery

The nasal septum is the wall (made of cartilage and bone) that divides the left side of the nose from the right side of the nose. Turbinates are a normal part of the inside of the nose. Their job is to filter and humidify air passing through the nose. Complications from nose surgery may include:

Bleeding: It is normal to have a small amount of bleeding after surgery on the nose and/or turbinates. If there is a lot of bleeding, your surgeon may have to look inside your nose and stop the bleeding. Sometimes this can be done in the office, but rarely this may have to be done in the operating room. There are a few things that may increase your chance of bleeding. Non-steroidal anti-inflammatory agents (NSAIDS, such as aspirin or ibuprofen) and certain over the counter (OTC) supplements such as vitamin E and gingko can increase the risk of bleeding, so patients should talk to their doctor about the use of any medications before or after surgery. If the bleeding causes a hematoma (blood clot) within the septum, this will need to be drained. This can lead to changes in the outside appearance of your nose if it is not drained.

Impaired sense of taste or smell: The sense of smell may get better after the procedure due to better airflow, although it could worsen depending on the extent of swelling, infection, or allergy. This impairment is often temporary.

Nasal obstruction: Much of the nasal septum is made of cartilage. Although measures are taken to prevent this at the time of procedure, the cartilage potentially could move back to its original position after surgery. Surgery typically improves airflow, but in some patients it may not improve, or rarely may worsen. Small scar bands may also occur in the nose and require removal by the surgeon.

Numbness: Numbness of the front upper teeth, lip or nose may occur after surgery but is usually self-limiting and does not require further treatment.

Change in appearance: The septum contributes to a significant portion of the bridge of the nose and the base of the nose near the upper lip. Although surgery on the septum alone typically doesn’t change the appearance of the outside nose, such changes are possible. Septal perforations (holes) can also occur but are usually not symptomatic.

Pain and dryness: The turbinates are a normal part of the inside the nose that filter and humidify air passing to the lower airway (lungs). They often become too enlarged and their size is reduced during nasal surgeries, and this often improves symptoms such as nasal congestion and obstruction. However, in rare patients this reduction can leave the patient with the sensation of being overly dry or even causing chronic pain; a very rare but severe form of this is referred to as “empty nose syndrome” or atrophic rhinitis.

Complications of Sinus Surgery

The sinuses are air-filled structures inside the bones of the face that produce and drain mucus into the nasal cavities. Complications from sinus surgery may include:

Intraorbital complications: (damage to the eye or surrounding tissue): The orbit is the cavity that houses the eyeball and its associated structures and is situated adjacent to the sinuses and is separated from them by a thin layer of bone. Because of the proximity, in rare cases, bleeding may occur into the orbit requiring treatment at the time of the initial surgery. Visual loss and blindness have been reported but are extremely rare. Another uncommon problem is damage to the muscles that move the eye leading to double vision, which can be temporary or permanent. In certain circumstances, there may be a change in the function of the tear ducts causing excessive tearing. Since the eye is near the sinuses, it is also possible for a major orbital complication or visual loss to occur even without surgery for patients with severe or refractory sinus infections.

Intracranial Complications: The intracranial cavity and sinuses are in close proximity; the roof of the sinuses is the floor of the skull. If this thin bony layer is fractured, brain fluid can leak into the nose. While rare, this is likely to be identified and repaired in the operating room at the time of the primary surgery. In rare cases, this could lead to infection of the lining of the brain (“meningitis”), bleeding into the brain or the need for further intracranial surgeries.

Voice changes: One of the functions of the sinuses is to affect resonance, so vocal professionals should be aware of potential changes in their voice after sinus surgery.

Impairment of smell or taste: (see above)

Infection: The most common reason to undergo sinus surgery is a chronic sinus infection that does not resolve with medications. The patient with sinusitis is therefore at risk of developing certain other infections in this area (abscesses, meningitis, etc.) from sinus surgery, although it important to recognize that this is also a potential complication of not undergoing surgery for a refractory chronic sinus infection.

Nasal obstruction, dryness, and pain: (see above)

What are the alternatives to endoscopic sinus surgery?

Continuing medical therapy alone and avoiding surgery is always an alternative. Medical therapy is chiefly antibiotics and/or steroids combined with other medications. As with any surgery, you should feel more than comfortable seeking a second opinion from another surgeon.