Surgery In Sinus Disease

Sypmtoms Of Sinusitus.jpgSinusitis affects 37 million people each year, making it one of the most common health problems in the U.S.1 It impacts a patient's quality of life and accounts for over $8 billion in annual healthcare expenditures. 

Two approaches have emerged for treating these patients: 

1. Medical therapies
2. Endoscopic interventions

Advancing Sinusitis Treatment
Medical therapies have advanced from basic remedies to an array of specialized drugs and sophisticated delivery methods. These treatments are often effective in reducing sinusitis symptoms. However, for many patients, these medications are inadequate and surgery may be their next step in finding relief. 

Sinus surgery has also evolved from open to less invasive surgical techniques. With the advent of FESS in the 1980s, surgery took an evolutionary leap forward with the elimination of open surgery, the introduction of endoscopic tools, and the discovery that blocked sinus ostia may be the primary culprit of this disease.

Sinus Surgery

The ear, nose, and throat specialist will prescribe many medications (antibiotics, decongestants, nasal steroid sprays, antihistamines) and procedures (flushing) for treating acute sinusitis. There are occasions when physician and patient find that the infections are recurrent and/or non-responsive to the medication. When this occurs, surgery to enlarge the openings that drain the sinuses is an option.

A recommendation for sinus surgery in the early 20th century would easily alarm the patient. In that era, the surgeon would have to perform an invasive procedure, reaching the sinuses by entering through the cheek area, often resulting in scarring and possible disfigurement. Today, these concerns have been eradicated with the latest advances in medicine. A trained surgeon can now treat sinusitis with minimal discomfort, a brief convalescence, and few complications.

A clinical history of the patient will be created before any surgery is performed. A careful diagnostic workup is necessary to identify the underlying cause of acute or chronic sinusitis, which is often found in the anterior ethmoid area, where the maxillary and frontal sinuses connect with the nose. This may necessitate a sinus computed tomography (CT) scan (without contrast), nasal physiology (rhinomanometry and nasal cytology), smell testing, and selected blood tests to determine an operative strategy. Note: Sinus X–rays have limited utility in the diagnosis of acute sinusitis and are of no value in the evaluation of chronic sinusitis.

Sinus Surgical Options Include:
Functional endoscopic sinus surgery (FESS): Developed in the 1950s, the nasal endoscope has revolutionized sinusitis surgery. In the past, the surgical strategy was to remove all sinus mucosa from the major sinuses. The use of an endoscope is linked to the theory that the best way to obtain normal healthy sinuses is to open the natural pathways to the sinuses. Once an improved drainage system is achieved, the diseased sinus mucosa has an opportunity to return to normal.

FESS involves the insertion of the endoscope, a very thin fiber-optic tube, into the nose for a direct visual examination of the openings into the sinuses. With state of the art micro-telescopes and instruments, abnormal and obstructive tissues are then removed. In the majority of cases, the surgical procedure is performed entirely through the nostrils, leaving no external scars. There is little swelling and only mild discomfort.

Research continues in this area at CSI with outcome studies looking at the avoidance of external, revision, and destructive surgical approaches. We have published papers that have demonstrated excellent frontal sinus outcomes and avoidance of external surgeries.

The advantage of the procedure is that the surgery is less extensive, there is often less removal of normal tissues, and can frequently be performed on an outpatient basis. After the operation, the patient will sometimes have nasal packing. Ten days after the procedure, nasal irrigation may be recommended to prevent crusting.

Image guided surgery: The sinuses are physically close to the brain, the eye, and major arteries, always areas of concern when a fiber optic tube is inserted into the sinus region. The growing use of a new technology, image guided endoscopic surgery, is alleviating that concern. This type of surgery may be recommended for severe forms of chronic sinusitis, in cases when previous sinus surgery has altered anatomical landmarks, or where a patient’s sinus anatomy is very unusual, making typical surgery difficult.

Image guidance is a near-three-dimensional mapping system that combines computed tomography (CT) scans and real-time information about the exact position of surgical instruments using infrared signals. In this way, surgeons can navigate their surgical instruments through complex sinus passages and provide surgical relief more precisely. Image guidance uses some of the same stealth principles used by the United States armed forces to guide bombs to their target.

Caldwell Luc operation: Another option is the Caldwell-Luc operation, which relieves chronic sinusitis by improving the drainage of the maxillary sinus, one of the cavities beneath the eye. The maxillary sinus is entered through the upper jaw above one of the second molar teeth. A “window” is created to connect the maxillary sinus with the nose, thus improving drainage. The operation is named after American physician George Caldwell and French laryngologist Henry Luc and is most often performed when a malignancy is present in the sinus cavity.

Balloon sinuplasty: This new device was first used by Cal Sinus. Patients who have undergone sinus surgery with this new device have fast recovery times and no packing. This involves the use of small balloons to expand the sinus drainage holes and not remove tissue - it's like angioplasty for the heart applied to the sinuses instead - hopefully faster recovery, no packing and much less pain than current endoscopic sinus surgery.
These would be good areas for video, Dr. Hepworth speaking about the procedure.

Turbinate

Risks vs. benefits (consent?)
Complications of Nasal and Sinus Surgery 

Surgery on the nasal septum, turbinates, and sinuses is recommended only after it has been determined that medical management has been unsuccessful. While these procedures are generally very successful, patients must be aware of certain risks before electing to proceed. These risks include, but are not necessarily limited to, the following:

• Postoperative bleeding: Aspirin, ibuprofen and certain non-prescription supplements (vitamin E, garlic, etc.) can increase the propensity to bleed, so patients should consult with their physicians before using these agents before or after surgery. Intranasal packing is utilized by many sinus surgeons to help avoid this complication but occasionally postoperative bleeding is encountered despite all precautions.

• Anesthesia complications: Adverse reactions to local or general anesthesia may occur, including cardiac and pulmonary complications. Fortunately, these risks are quite rare in this era of modern anesthesia.

• Intracranial complications: The base of the skull forms the roof of the ethmoid and sphenoid sinuses.

• If this layer is violated, a leak of cerebrospinal fluid (the fluid that bathes the brain and spinal cord) may occur (Figure 1). This can usually be repaired at the time of the initial surgery, although in rare cases further complications such as meningitis may ensue.

• Intraorbital complications: The orbit is situated immediately adjacent to several of the paranasal sinuses but is separated by a layer of bone. Because of this close proximity, in rare cases bleeding may occur into the orbit requiring repair at the time of the initial surgery. Visual loss and blindness have been reported but are extremely rare.

• Smell: The sense of smell usually improves, although it may occasionally worsen, depending on the extent of infection, allergy or polyps.

• 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.

• Infection: The most common reason to undergo sinus surgery is a chronic 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.) regardless of whether they manage the sinusitis with or without surgery.

• Nasal obstruction: Much of the nasal septum is made of cartilage, which has "memory" - the propensity to move back to its original position. Despite certain measures performed by the surgeon at the time of septoplasty this may still occur and require a secondary procedure. Small scar bands may also occur in the nose
and require removal by the surgeon at postoperative visits.

• Numbness: A transient numbness of the front upper teeth, lip or nose may occur after surgery but is usually self-limiting.

• While surgery may entail these complications, it is also crucial to remember that the failure to intervene surgically may also place the patient at risk for certain complications. When left untreated, the infection may rarely spread to adjacent structures such as the eye or brain and lead to abscesses in these areas, meningitis, visual loss, or even death. Fortunately, the rare patient suffers from complications of the infection or sinus surgery.

Acknowledgments
Jay M. Dutton, MD
Rush-Presbyterian-St. Luke's Medical Center
Chicago, IL
Original diagram provided courtesy of AstraZeneca LP and modified by Jay M. Dutton, MD.

Preoperative care-
Patient Information, Resources, FAQs, and LINKS
How do I make an appointment? Conect to contact us page
What should I bring to my appointment?
• We want to answer as many of your questions at your visit. Please prepare for this by bringing:
• Health Insurance Card/Information
• A friend or family member to take notes/help with questions
• A list of all medications you are taking
• A list of your questions /concerns
• A copy of your XRAYS / CT scans (not the reports - get the actual films)
• Copies of records from doctors related to your sinuses/nose/allergies/lungs.
• Completed FORMS
What forms can I print and fill out before my appointment?- We need these
How do I get the CSI newsletter?- we need this or can help create

Questions about sinus surgery? Although many sinus-related problems can be treated with medicines, surgery may be needed in some patients. Whenever possible, CSI surgeons use newer, less deforming, and less painful techniques. The most common type of sinus surgery is Functional Endoscopic Sinus Surgery (FESS). In FESS, your CSI surgeon will use small cameras and instruments to work carefully in the nose. They will remove obstructing tissues, allowing the sinuses to drain more naturally. This should decrease the severity, frequency, and duration of infections. In some cases your surgeon may suggest surgery that includes "surgical navigation" -- usually with a special type of CT or MRI scanner -- in order to diminish the chance of complications and improve results.

For more education on sinus surgery, please visit the following valued links:
Postoperative care
What to Expect After Sinus Surgery 

Many studies have demonstrated that the vast majority of patients who undergo endoscopic sinus surgery are ultimately very satisfied with their results. As with all surgeries there is a convalescent period after this procedure, although it is usually much milder now than in years past with the advent of endoscopes, minimally invasive procedures and smaller or absorbable packs. This recovery period can vary greatly depending on the extent of surgery, the use of nasal packing and the individual patient.
Patients will often experience blood-tinged discharge during the first day or two after surgery. This is normal, and by keeping the head elevated above the heart (a recliner works very well) this symptom will be minimized. Discomfort is generally well managed with pain medications prescribed by your surgeon. All patients will experience some degree of congestion or nasal obstruction, and this will be significantly improved once any nasal packing or splints are removed. In addition, patients may notice postnasal drainage, headaches, and fatigue that is most noticeable the first few days after the surgery and gradually resolves completely over the ensuing weeks. Many of these symptoms will mimic those of a sinus infection until this healing process is complete.
Patients should avoid strenuous activities and medications that predispose to bleeding (aspirin, ibuprofen, certain herbal remedies) for at least two weeks after surgery or until the healing process is complete. Time off work varies from several days to even weeks depending on the patient's occupation and the extent of surgery, and this should be discussed with your physician.
The postoperative care may be as important as the surgery itself. Sinus surgeons usually schedule frequent postoperative visits to clean the sinus cavities and ensure that they are patent, healing well and are without scarring. In addition, the surgeon will often have patients on a regimen to clean the sinus cavities at home although this varies greatly from physician to physician. For most patients, following the routine set forth by the sinus surgeon leads to excellent long-term results and patient satisfaction! 

Acknowledgments
Diagram provided courtesy of American Academy of Otolaryngology-Head & Neck Surgery. Jay M. Dutton, MD
Rush-Presbyterian-St. Luke's Medical Center
Chicago, IL 

Disaster recovery surgery
Resources for the desperate patient—too much previous surgery