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Medical Treatment of sinus problems
Sinus surgery information
Anatomy of the nose and sinuses
Treating sinus polyps
The sinuses and snoring problems
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Powered Instrumentation sinus procedures
Sinus image guidance information
Sinus problems and quality of life
Effect of fungus on sinuses and sinusitis
FESS and rhinoplasty
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Surgical Treatment of the Sinuses
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Question: Who is a candidate for sinus surgery?
Answer:
Sinus surgery is a treatment of last resort. Most patient symptoms can be improved with a variety of medical and allergy treatments. For patients whose symptoms persist, and do not respond to medical interventions sinus surgery may be warranted. In particular, patients who have anatomical abnormalities that lead to persistent or recurrent obstruction of the sinus drainage pathways may benefit from a minimally invasive sinus procedure. In other patients with more severe anatomical abnormalities, more aggressive interventions may be required.

Question: What are the goals of sinus surgery?
Answer:
In some patients with chronic sinusitis, anatomical abnormalities contribute to the persistent swelling, edema, and infections that may occur in the sinuses. Often this has to do with blockage of the small pathways through which the sinuses drain. By surgically opening and enlarging these pathways, the sinuses can drain more naturally and freely. Also, when the sinuses are "nasalized," or open to the nasal passage, topical nasal sprays can reach into the sinuses where they can further decrease inflammation without the systemic effect of oral medications. When patients do have sinus infections (and sinus surgery does NOT mean you will never get another sinus infection), the sinuses are now open so the infection can be cultured in clinic under endoscopic guidance. With results from a culture, the correct antibiotic can be chosen, so that patients decrease the incidence of unnecessary and ineffective treatments, as well as the development of resistant bacteria.

Question: If I have sinus surgery will I be done with sinus infections forever?
Answer:
As noted above, having sinus surgery does NOT mean you will never have another sinus infection. The goals of surgery are to decrease the frequency of sinus infections, as well as to hasten the recovery time when you do get an infection.

Question: How is sinus surgery performed?
Answer:
Most sinus surgery is performed through the nose using small (4 millimeter diameter) endoscopes. Using the endoscope, the surgeon finds the natural openings of the sinuses which have been blocked by swollen tissue. The blockages are removed and the natural openings are enlarged with small instruments also placed through the nose. In recent years there have been a variety of technological developments which have increased the range and variety of instruments available to open these blockages. Your surgeon will decide – based on your history and anatomy – which instruments and methods are most appropriate for your surgery.

Question: What is "functional endoscopic sinus surgery?
Answer:
The nasal and sinus passages have a lining that clears mucous and foreign irritants in order to maintain a healthy environment. In “functional” surgery, care is taken to remove the offending portions of anatomy while sparing as much of the nasal and sinus lining as possible. This allows for maximal effect of the surgery in an attempt to regain a healthy, normal sinonasal environment. Most sinus surgery today is "functional endoscopic sinus surgery," or "FESS." As noted above, the surgery is usually performed through the nose (endonasal) and the areas are visualized with the use of a small (4mm) endoscope ("endoscopic sinus surgery").

Question: What is this balloon stuff I keep hearing about?
Answer:
In the past several years there has been an application of heart catheter technology to the sinuses. In particular, 2 companies (Acclarent and Entellus) have devised tools to open and enlarge the sinus openings (ostia) with the placement of small balloons which are then inflated under steady pressure. These tools are appropriate for some, but not all patients who undergo sinus surgery. Your surgeon will discuss this with you if he/she feels that you would benefit from the use of balloon technology during your sinus procedure.

Question: What is image-guided sinus surgery?
Answer:
When operating in the sinuses, surgeons strive to perform safe, efficient, and complete surgery. Image guidance systems are now routinely available at most surgery centers. These are, in essence, “GPS” systems for the sinuses which track the location of the surgeon’s instruments within several millimeters.

Question: If I have sinus surgery, will I need surgery again?
Answer:
For the vast majority of patients who undergo sinus surgery, no further surgery will ever be required. In fact, many studies have demonstrated that the vast majority of patients who undergo endoscopic sinus surgery are ultimately very satisfied with their results. There are some patients; however, who will undergo revision procedures. This may be due to post-operative scarring after the initial surgery, progression of disease after the initial surgery, or other reasons. In most patients who do undergo revision procedures, the amount of surgery required is less than the initial procedure, since these cases tend to require "touch ups" at specific sites.

Question: What if I already have had sinus surgery and I am still suffering?
Answer:
Patients who have had surgery and have persistent signs and symptoms of sinusitis should be seen by a trained otolaryngologist. Your otolaryngologist has a variety of tools to help pinpoint the source of your persistent problems. An in-office endoscopy can be performed in the matter of minutes and may reveal obvious anatomic causes of persistent symptoms, such as post-operative scarring. Sinus CT scans, allergy testing, and other diagnostics can also be performed to help find the source of persistent sinusitis after sinus surgery. In many cases, patients respond to a simple change of medication. Other cases may require a revision procedure.

Question: What can I expect the day of surgery?
Answer:
Most sinus surgery is performed as an outpatient procedure, often at ambulatory surgery centers. Typically patients will be notified the day before surgery and told when to arrive at the surgery center. Arrival time is NOT the same as surgery time. You will be asked to arrive a few hours prior to your surgery time to review surgical logistics, and meet your anesthesia team. In most cases, patients will be told not drink or eat after midnight. If you are taking asthma inhalers, or other chronic medications, you will often be asked to bring these with you. In the private waiting areas, patients meet with their anesthesia team and discuss their medical history and prior anesthesia history. If the patient has a history of adverse reactions to anesthetics or other medications, it is essential to communicate this to the physicians and nurses. During this same time, nurses will review with the patient all pre-operative records, confirm the nature of the proposed surgery, and administer any required pre-operative medications. Patients should remember that they will not be able to drive themselves home after surgery center. A designated driver (usually a family member) is required for surgery to proceed.

Question: What can I expect the night after surgery?
Answer:
The night after sinus surgery most patients try to relax at home (or in a hotel if they have traveled a long distance). Patients may have a sore throat for a day or two as a result of the endotracheal tube (breathing tube) used by anesthesia during the surgery. Patient s can expect mild to moderate pain after surgery. While pain is not typically a large complaint after sinus surgery, patients should take their prescribed pain medications (as they are prescribed) if they feel the need. Allowing pain to progress will increase patient blood pressure which in turn may increase post-operative bleeding. It is normal to have a small amount of by red (bloody) nasal drainage. For a few days after surgery, it may be useful to elevate the head of your bed. This will likely increase your comfort and decrease nasal bleeding. Most patients will experience some level of fatigue for the first 1-2 weeks after surgery. It is important to remember that just because you look the same (no big casts on your arm) and do not have much pain does not mean that you did not have surgery. You will need to give your body time to recover from the procedure.

Question: What are some tips for the immediate post-operative period?
Answer:
Here are some important tips to remember during your immediate postoperative period:

  • Cough and sneeze with your mouth open.
  • Do not blow your nose.
  • If you have nasal congestion, sniff and spit into a tissue.
  • Keep the head of your bed elevated.
  • Alert your doctor for any of the following - excessive bleeding, pain not controlled by pain medication, or vision problems

    Question: How much pain should I expect after sinus surgery?
    Answer:
    Sinus surgery is not typically associated with a high degree of post-operative pain. Patients are given narcotic pain medications (ie – Tylenol with codeine) to help manage any pain they may experience. Typically patients seen a few days after surgery will report that they take 1-2 pain pills a day. By 1 week most patients are doing well with over the counter pain medications like Tylenol.

    Question: Is there a lot of bleeding during sinus surgery?
    Answer:
    Most patients have minimal bleeding during sinus surgery (less than 50 ccs of blood loss). Patients with a history of bleeding disorders, easy bruising, bleeding when brushing teeth, heavy menses, etc should be evaluated closely prior to surgery. If you have a history of easy bleeding or bruising, make sure to bring this up to your doctor during your pre-operative discussions.

    Question: How often do I have to come back to see my doctor after sinus surgery?
    Answer:
    Your doctor will want to see you fairly often after surgery. Typically you will be seen several times in the first 6-8 weeks after surgery. This is to make sure that you heal well. During these visits your surgeon will use a small endoscope to inspect your surgical site and remove crusting that is present. This is an important aspect to having a successful outcome after your surgery.

    Question: What can I expect in the days and weeks after sinus surgery? When can I resume my normal daily activities?
    Answer:
    Most patients are advised to plan for 1 week off of work after nasal and/or sinus surgery. During this week patients should expect to have a small amount of pain which is typically well-controlled with prescribed medications. Ironically, many patients will have worsened nasal obstruction/congestion for the 7-10 days after surgery due to expected swelling after surgery. If this becomes bothersome, it can often be managed with an oral steroid pack. Patients should also expect to have fatigue during this first week or two after surgery. Most patients go back to work at the start of the second week after surgery. Patients typically feel well enough for work during this week, but do not feel "100 percent." After two weeks most patients are back to their baseline. At 1 month most patients typically feel the positive effects of their surgery. This should continue to improve over the months to come.

    Question: Is there packing placed after surgery? Will I have "black and blue" marks?
    Answer:
    In years past, packing was used routinely after septoplasty and sinus surgery and associated with significant post-operative pain and discomfort. In today’s surgical environment, the use of non-absorbable packing is much less common. In many cases your doctor may use no packing at all. In some cases, your doctor may decide to leave small silastic splints in place for a few days. These splints typically have ports to allow air to pass in and out of the nose and are well-tolerated by patients. Splints are usually removed in the office a few days after the surgery. Splint removal typically takes under 60 seconds and is well-tolerated. In the case of significant bleeding your doctor may decide to use non-absorbable packing. With the easy availability of modern endoscopes and small surgical cautery devices for the management of nasal and sinus bleeding; however, this is uncommon. With traditional septoplasty there are no external incisions, and black and blue marks are for the most part a thing of the past.

    Question: Do I need a septoplasty?
    Answer:
    The nasal septum sits roughly in the midline of the nose and separates the right and left sides. If the septum is deviated, or tilted to one side it may decrease the nasal airflow on that side. Sometimes when the septum is deviated it may also push surrounding structures to the sides of the nose so that they obstruct the sinus drainage pathways. When septal deviation is found to contribute to symptoms of nasal obstruction, congestion, and – in some cases – sinusitis, surgical correction may be warranted.

    Question: What is a septoplasty?
    Answer:
    The nasal septum is like an Oreo cookie – it has lining on each side with bone and cartilage "filling" in the middle. In a septoplasty, a small, hidden incision is made inside the nose, and the surgeon dissects underneath the lining. The deviated, obstructing portions of the bone and cartilage are removed, and the lining is then sewn back together so that it may heal. Sutures are dissolvable and do not require removal.

    Question: What are the possible risks and complications of septal and sinus surgery?
    Answer:
    Sinus surgery is considered safe, outpatient surgery and is performed on a routine basis in the United States. Complications do occur; however, and these should be reviewed during the informed consent process. A review of the national and international literature has revealed the following complications that have occurred in patients around the world. These include but are not limited to bleeding/hemorrhage, infection, anesthetic risk, persistence/ recurrence/ or even worsening of the problem (including the need for revision surgery), scarring, decreased or loss of smell and/or taste, changes to the voice, need for further surgery, temporary or permanent numbness of the upper lip/teeth/cheek and/or nose, atrophic rhinitis/empty nose syndrome, epiphora (persistent tearing), temporary or permanent numbness of the eyebrow and forehead (after frontal sinus trephination), septal hematoma, saddle nose deformity, and septal perforation. More severe risks to surgery include damage to surrounding structures, including the eyes with possible double vision and blindness and including the brain with possible cerebrospinal fluid leak, meningitis, abscess, seizures, stroke and death. These complications are reviewed in more detail in the Online Textbook (Chapter on Sinus Surgery).

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