The soft tissue shaver helps make this procedure routine. The shaver allows for excellent visualization of the anatomy while the polyps are precisely and quickly removed. The continuous suction allows relatively uninterrupted dissection in a clear field. Packing is usually not required. Overall, a more complete removal is possible with less bleeding and greater comfort.

Guarded bone drilling burs are also available in various configurations for removal of larger quantities of more dense bone. For example, these burs are used in frontal sinus "drillout" procedures to re-establish proper frontal sinus drainage in some advanced cases of chronic frontal sinusitis.

Question: Tell me about computer-assisted or image-guided endoscopic sinus surgery.
Answer: Computer-assisted surgery was initially developed for accurate localization during neurosurgical procedures. The application of this technique in endoscopic sinus surgery is now available in many major sinus centers. This system allows the surgeon to localize the tip of the surgical instrument in the paranasal sinuses, generally within 2 mm of accuracy on coronal, axial, and sagittal CT images. Computer-assisted endoscopic sinus surgery can potentially aid the surgeon, especially when working in or near difficult areas such as the frontal sinuses, sphenoid sinus, skull base and orbit. Computer-assisted endoscopic sinus surgery is used primarily in cases with poor surgical landmarks caused by previous surgery, dense scarring, or extensive disease.

These systems are not universally available. While they are helpful in specific cases, they are not always necessary for an experienced, skillful surgeon to perform difficult procedures. While they do provide potential advantage in specific situations. They are not, at this stage, associated with decreased surgical risk.

Question: What can the patient expect to experience after surgery?
Answer: FESS is usually performed on an outpatient or ambulatory basis. The authors do not routinely use any nasal packing after FESS. Patients seem to be much more comfortable when no nasasl packing is used.

The post-operative care is as important as the surgery itself. Patients are instructed to use both saline nasal spray and saline irrigations in the nose several times a day to cleanse the nose of crust and clots. This maintains a healthy, moist environment to optimize healing.

Periodic endoscopic cleanings are performed during the early healing stage to prevent formation of granulation tissue, adhesions, and scars that can reobstruct drainage of the sinuses. Usually the nasal mucosa has healed and normal mucociliary flow is re-established within 6 weeks.

The patient can expect to experience some bleeding from their nose for several days after the surgery and again after each office debridement. This is normal and slowly improves. When bleeding occurs down the front of the nose or into the back of the throat, the patient should tilt their head back while sitting up and breathe gently through their nose. If bleeding persists for an extended period of time, notify the surgeon's office.

As the sinuses begin to clear themselves after two to three weeks, the patient can expect to have some thick brown drainage from their nose. This is mucus and old blood. This is expected and does not indicate an infection.

The patient may experience some discomfort after surgery due to manipulation and inflammation. The patient should take their pain medication as directed (Tylenol with Codeine, for example. Often, extra-strength Tylenol is sufficient). The surgeon may advise the patient to take medication for pain prior to their postoperative visits, when the nose is most sensitive. If the medication is sedating, the patient should be sure to have someone available to drive them.

Question: Are there some important DOs and DON'Ts after surgery?
Answer:

DO NOT blow your nose until you have been given permission to do so (usually one week following surgery)

DO NOT bend, lift or strain for at least one week following surgery. These activities will promote bleeding from your nose. You should not plan on participating in rigorous activity until healing is completed.

DO NOT suppress the need to cough or sneeze, but cough or sneeze with your mouth open.

DO NOT use any aspirin-containing products until after discussing this with us. Usually, you can restart after 7 to 10 days.

DO use nasal saline spray (without decongestant) every hour while you are awake until instructed otherwise. This helps moisten the nose and prevents large crusts from forming.

DO continue your antibiotics until instructed otherwise. Diarrhea from antibiotic use can lead to a serious health problem. This can often be prevented by taking acidophilus daily, which is found in yogurt with active cultures or as tablets in a health food store. If you should experience any diarrhea, stop the antibiotic and notify us. Further evaluation may be required.

DO notify us for any of the following: temperature elevations above 100.5F, clear watery drainage from your nose, changes in vision, swelling of the eyes, worsening headache, or neck stiffness.

Question: What can you tell me about postoperative visits?
Answer: Postoperative visits are an indispensable part of the surgery that helps promote healing and prevents persistent or recurrent disease. Follow up visits are usually arranged at approximately six days after surgery to clean crusts from the nose. A family member or friend should drive the patient to and from the first postoperative visits, and thereafter as instructed by the surgeon.

The patient should anticipate periodic visits to the surgeon's office until healing is nearly completed (usually 4 to 6 weeks). During follow up visits, any persistent inflammation or scar tissue will be removed under local anesthesia. Although the chances of complications from these manipulations are rare, the potential risks are the same as with the surgery itself. Consent to surgery also includes consent to postoperative care.

Careful postoperative care is essential to the success of this surgery. The authors' patients are provided with postoperative care instructions. It is very important that the patient follow these instructions, as well as any other instructions given by the surgeon, to promote healing and decrease the chance of complications.

Question: Will endoscopic sinus surgery cure sinus problems?
Answer: Overall, the majority of patients have had significant improvement with the combination of surgery and continued medical management. FESS performed as a result of medical therapy failures in acute and chronic sinusitis is associated with a success rate of 75 to 95% according to sources in the literature.

Sinusitis is a chronic problem, and while your symptoms may improve or even disappear after surgery, your nose and sinuses still have the potential to be irritated by pollen, dust, pollution, etc. It should be realized that some medical therapy is usually continued after surgery, especially if allergy or polyps play a role in the sinus disease. This is necessary to control or prevent recurrence of disease.

It is possible that the disease may not be cured by the operation, or that the disease may recur at a later time. If this should happen, subsequent surgical therapy may be required.

Question: What are the risks of Endoscopic Sinus Surgery?
Answer: The potential complications of FESS include the same potential complications of traditional sinus surgeries. There are potentially serious risks from surgery in this area; however, the incidence of these risks is low. Even in the best of hands, surgical complications can occur.

Bleeding. Although the risk of bleeding appears to be reduced with this type of sinus surgery (i.e., FESS), on occasion significant bleeding may require termination of the procedure and the placement of nasal packing. Bleeding following surgery could require placement of nasal packing and hospital admission. A blood transfusion is rarely necessary. Post-operative hemorrhage is uncommon with FESS, but is more likely when inferior turbinate resection or partial middle turbinectomy is performed.

Blood Transfusion. In the very rare instance that a blood transfusion is necessary, there is a risk of adverse reaction or the transfer of infection.

Cerebrospinal (CSF) fluid leak. All operations on the ethmoid sinus carry a small chance of creating a leak of CSF (the fluid that surrounds the brain). The risk of CSF leak is generally considered higher when ethmoid surgery is done through the nose instead of through an external incision. However, because the endoscope used allows improved visualization, the risk of complications is potentially reduced. Should this complication occur, it creates a potential pathway for infection which could result in meningitis (inflammation of the brain or a brain abcess). A CSF leak is typically repaired at the time of the sinus surgery if it is recognized. A CSF leak would extend the patient's hospitalization and may require further surgery for repair.

Decreased sense of smell. Permanent loss or decrease in the sense of smell can occur following surgery. However, in a number of patients, it is already decreased prior to surgery, and typically it improves with surgical intervention.

Visual problems. Orbital injuries may include exposure of orbital fat, hemorrhage into the orbit, extra-ocular muscle injury, globe injury or optic nerve injury. Although extremely rare, there are occasional reports of visual loss after sinus surgery. Usually, loss of vision only involves one side and the chance for recovery is poor. Temporary or prolonged double vision has also been reported after sinus surgery.

Anesthesia risks. Because sedation or general anesthesia is often used, the patient would be subject to the occasional but possibly serious risks involved. Adverse reactions to anesthesia may be further discussed with the anesthesiologist.

Nasal Septal Surgery Risks. In some cases it may be necessary to repair the nasal septum at the time of sinus surgery. If this is required, additional risks associated with septal surgery are possible. If nasal septal surgery is performed, you could experience numbness of the front teeth, bleeding and infection in the nasal septum, or the creation of a septal perforation. A septal perforation is a hole in the septum, which may cause difficulty breathing through the nose. It can also lead to bleeding, whistling or crusting from the nose. Since the cartilage in the septum has a "memory" it may shift postoperatively and result in a renewed deviation. There is also a small risk of a change in the shape of the nose.

Other risks:

Tearing of the eye can occasionally result from sinus surgery or sinus inflammation and may be persistent. The patient may experience numbness or discomfort in the upper front teeth for a period of time. Swelling, bruising, or temporary numbness of the lip may occur, as well as swelling or bruising around the eye.

Scars or "synechiae" can form postoperatively, and if not recognized they can lead to obstruction of the sinuses and recurrence of sinus symptoms. Meticulous post-operative care by both the patient and the otolaryngologist will minimize problems with synechia.

Question: Tell me a little bit about FESS technique.
Answer: Endoscopic sinus surgery is performed in either an anterior to posterior (front-to-back) direction, or posterior to anterior. In general, the anterior to posterior technique may be considered the more conservative approach and is best for limited disease that involves the anterior, ethmoid, maxillary or frontal sinuses. The posterior to anterior technique may be used for patients with pansinusitis or in patients that have had prior sinus surgery that resulted in loss of anatomic landmarks. The skillful sinus surgeon has both techniques in his or her armamentarium and may apply them as the need arises.

The Deviated Septum and Some Other "Non-Sinus" Causes of Nasal Problems

Question: What is a deviated septum?
Answer: The septum is the wall that divides your nose down the middle, into a right and left side. It is made of cartilage and bone and has a mucous membrane lining on both sides.

When the septum is straight, it simply acts as the divider of your nose and allows for streamlined, aerodynamic airflow and easy nasal breathing. If it is deviated or twisted it can cause nasal obstruction. The septum can twist to the right and block the right side, and then come around further back in the nose and twist to the left to block the left side too!

Question: How do you treat a deviated septum? What is a septoplasty?
Answer: There is no medicine that can straighten a deviated septum. If your septum is causing nasal obstruction, only surgery can correct it. This surgery is called a septoplasty.

A septoplasty is performed through a small incision made on the inside of the nose (no external incisions!). The lining of the septum (the mucous membranes) are lifted off of the cartilage and bone. The cartilage and bone are sculpted, repositioned, and a portion of it may be removed to achieve the desired straightening of the septum. The mucous membrane lining is then sewn back together with absorbable sutures (no stitch removal necessary!)

The surgeon may place a small nasal packing that is removed the next day. The packing is placed to provide light pressure on the septum to optimize healing, to prevent excessive swelling or bleeding. Our patients do not find this uncomfortable, and they do not find the removal of this packing to be painful. In the past, a kind of packing was used that was uncomfortable. We do not use this packing, but rather we use a state-of-the-art, "slim-line" packing that our patients have given their seal of approval!

The surgery is performed under sedation anesthesia or general anesthesia, and typically takes 30-45 minutes to perform. For more information on surgery for deviated septum, see Dr. Becker's published paper on Septoplasty and Turbinate Surgery (Acrobat .pdf format).

Question: What is a concha bullosa? How do you treat it?
Answer: A concha bullosa is an aerated middle turbinate. These occur developmentally and can be found in a small but significant number of patients.

The aerated middle turbinate is like a "balloon" in your nose -- it takes up space in the nasal cavity and narrows the nasal passageways. Opening up this "balloon" frees up this space for nasal breathing. It is important for your doctor to check if you have a concha bullosa, as they occur commonly enough that they should be found and treated to provide you with the best nasal breathing possible.

Question: What is an inferior turbinate? How do you treat them?
Answer: The turbinates are structures that exist in your nose and play an important role in nasal breathing. In the winter they moisturize and warm the cold dry air as it flows through your nose. In the summer the turbinates also play an important role in air conditioning as you breathe air through your nose.

Also, the turbinates provide some resistance to airflow, and they contain nerves that sense airflow. The resistance and the sensation of airflow are important to our sensation of nasal breathing. When the turbinates are too swollen, the patient feels nasal obstruction.

When medical treatment does not sufficiently shrink the turbinates, conservative surgical therapy may be necessary.