What is sinus surgery

The aim of sinus surgery is to widen the passage between the sinus and your nose so that mucus no longer becomes trapped. Sinus surgery should prevent the sinusitis from coming back but your sense of smell may not improve.

When medical treatments for chronic sinusitis or recurrent acute sinusitis don’t provide sufficient relief from your symptoms, sinus surgery may be an appropriate option for you. Sinus surgery is usually performed under a general anesthetic but a local anesthetic can be used. Sinus surgery usually takes 1 to 2 hours.

Patients who are candidates for sinus surgery include:

• Chronic Sinusitis – A sinus infection that just will not go away in spite of several courses of antibiotics, ideally culture-directed. Studies include an abnormal CT Sinus scan and allergy testing to determine if the sinus infection may be allergy driven. Immunological studies may or may not be obtained as well.
• Recurrent Acute Sinusitis – Multiple discrete sinus infections per year (more than 4 annually) of which at least one has been documented on CT Sinus scan and/or via nasal endoscopy. Ideally, antibiotics tried should include one that has been culture-directed. Patient has also been tried and failed to respond with allergy treatment. Immunological studies are warranted to evalute for any immunodeficiency.
• Nasal Polyps – Sinus symptoms due to polyps that may fill both the nasal and sinus cavities leading to symptoms of congestion, obstruction, sinusitis, and loss of smell. Nasal polyp presence is confirmed on both CT Sinus scan as well as nasal endoscopy.
• Sino-Nasal Mass – Finally, the last category is a yet undefined mass which includes cancer.

There is often the mistaken belief that sinus surgery prevents sinus infections. This is not directly true. Rather, by enlarging the natural sinus openings, there is less chance of clogging which often leads to persistent sinus infections. The natural openings of your sinuses are only several millimeters in size and it doesn’t take much for them to get swollen shut. Once the natural openings of your sinuses are enlarged through sinus surgery, there is less risk of blockage. If sinus infections occur, they readily drain and are cleared quickly. Also, sinus surgery is often just a tool that helps long-term medications work more effectively.

So, most patients experience a decrease in frequency and severity of sinus infections after sinus surgery.

The other benefits of sinus surgery are that by having large sinus openings, saline sinus flushes work much better and your surgeon is now able to directly visualize the sinus cavities using an endoscope to monitor for sinus disease. Experts recommends regular use of saline flushes both before and after sinus surgery. ENT (ear, nose and throat) surgeon may typically suggest Neilmed sinus rinse kit, though many patients prefer the irrigation devices due to ease.

There are risks with sinus surgery. The most common is a nosebleed. As such, it is not uncommon to have packing placed in the nose after sinus surgery. Depending on your surgeon, nasal packing may be placed only <10% of the time. If nasal polyps are present, the percentage increases.

Other theoretical risks include eye/vision damage as the eyeball is right next to the sinus cavities separated only by a thin wall of bone. The other risk is the potential for a cerebrospinal fluid leak (“brain” fluid leakage). This particular risk occurs when the roof of the nasal cavity sustains a small fracture allowing the fluid around the brain to leak into the nose much like a leaky roof after a rainstorm. Why could this happen? Remember that the floor of the brain case is also the roof of your nose.

Regardless of the risk, they are all correctable. Read our consent form that we have all patients sign prior to sinus surgery.

There is technology to decrease the risk of complications known as 3D Image-Guided Sinus Surgery. Think of this high technology as GPS for the surgeon to safely navigate around your sinus cavities.

What are alternatives to sinus surgery?

Before resorting to surgery, a doctor will attempt a variety of other treatments. There is a range of medications that may be issued, as well as other procedures that may improve symptoms.

These other treatments include:

• antibiotics
• nasal saline rinses or sprays
• nasal decongestant sprays
• nasal steroid sprays
• oral steroids
• allergy medications
• antihistamines

Types of sinus surgery

The most common type of sinus surgery is endoscopic sinus surgery. However, there are other procedures that may be carried out.

Endoscopic sinus surgery

Endoscopic sinus surgery also called functional endoscopic sinus surgery (FESS), is a surgical procedure and treatment option for those with chronic sinusitis or recurrent acute sinusitis. An endoscopic sinus surgery is performed through your nostrils and does not result in any facial scars or change to the outside shape of your nose. Your surgeon will use a small telescope to examine your nasal passages. Your surgeon will use instruments to remove any polyps and to widen the passages from your sinuses into your nose.

The goal of sinus surgery is to widen the natural openings of the sinuses, which allows better distribution of topical therapies to the sinus cavities, such as topical saline, steroids, or antibiotics. In addition, the enlarged holes make it easier for sinus mucus to drain, even when swollen from infection or environmental irritants.

In a nutshell, endoscopic sinus surgery is when the natural openings of the sinuses into your nasal cavity are enlarged. If any diseased mucosa like nasal polyps or pus accumulation are present, these are removed as well. The surgery itself is all done via small cameras so that there are no incisions on the face. It is not usual that a patient has any bruising, swelling, black eyes, or any other facial appearance changes after surgery. Most patients are surprised by how little pain there is afterwards.

If you are a candidate for endoscopic sinus surgery, a sinus CT scan will be ordered to assess the extent of your condition and allow your surgeon to plan his or her surgical approach based on your unique sinus anatomy.

Patients are put under general anesthesia for the duration of the surgery, which generally lasts from about one to three hours depending on the severity of the patient’s condition. Patients usually go home the same day of surgery, unless other medical conditions warrant a hospital stay.

Image-guided sinus surgery

Image-guided endoscopic sinus surgery is a newer procedure that may be recommended for severe forms of sinus blockages or after previous sinus surgeries.

In addition to using an endoscope, this type of surgery uses a near-three-dimensional mapping system to show the surgeon the position of the surgical instruments. This is done using CT scans and infrared signals.

Using this guidance, a surgeon can navigate difficult sinus passages and remove tissues and other blockages accurately.

Caldwell-Luc operation

This procedure is less common and more invasive. It tends to be carried out when there is a growth present inside the sinus cavity.

The Caldwell-Luc operation aims to remove growths and improve sinus drainage. It creates a pathway between the nose and the cavity beneath the eye called the maxillary sinus. This window then aids drainage.

The surgeon makes a cut in the upper jaw, above one of the second molar teeth inside the mouth. They then enter the sinus cavity through this cut. This surgery may be performed under local or general anesthetic.

Sinus surgery risks

General risks of surgery:

• pain
• bleeding
• infection of the surgical site (wound)
• blood clots
• reactions to anesthetics

Specific risks of sinus surgery:

• adhesions, where scar tissue forms deep inside your nose
• damage to the bone around your eye
• blindness
• leak of fluid from your brain
• double vision
• toxic shock syndrome
• damage to your tear duct
• reduced sense of smell

Sinus surgery recovery time

You should be able to go home the same day. Most patients will usually be comfortable enough to go home an hour or two after the procedure. If you had non-dissolvable packing in your nose, you will need to stay overnight and the packing will be removed the next morning. However, some surgeons do not usually place packing in the nose as this can cause discomfort.

Do not blow your nose for at least a week. Your nose will continue to feel blocked for a few weeks.

Your surgeon will give you a nasal spray or drops for you to use and you may be given a course of antibiotics to reduce the risk of infection.

Regular exercise should help you to return to normal activities as soon as possible. Before you start exercising, ask the healthcare team or your doctor for advice.

For the first few days, a feeling of a “head-cold” is normal and this may resolve before the first office visit 1 week after the procedure. The nose is cleaned at the follow-up visit and most patients are able to go about their normal activities. An improvement in ease of breathing and a decrease or complete elimination in the frequency and severity of sinus infections is common.