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
Functional Endoscopic Sinus Surgery (FESS) with VTI (Computer Guidance)
Sinus surgery is indicated when medical therapy has failed to treat sinus problems/ infections. We are careful to evaluate each patient individually based on their symptoms and CT scan findings, to determine if surgery is necessary. If surgery is needed, it generally can be performed as an outpatient.
The procedure takes about 1 ½ -3 hours depending on the amount of surgery that is needed. It is performed under a general. We use small telescopes (similar to the size of a pen) that are passed through the nose to visualize the anatomic structures within the nose and sinuses. Small manual forceps and electric swiveling instruments are used along with suction devices to clean out the sinus cavities and enlarge their openings so that future sinus material can drain out more easily.
Generally, no external or visible incisions are necessary. The procedure does involve working close to the eye (orbit) and the brain; so potential for injuries to these areas is possible, but unlikely (less than 1% of the time). Following surgery, some pain can exist for 1-7 days, and sometimes packing may need to be removed from the nose following surgery (at the post operative visit). Occasionally, a second trip to the operating room may be needed about 2- 6 weeks following surgery to clean out the nasal/sinus cavities. The surgery is successful in improving sinus problems about 85 % of the time. Occasionally, revision sinus surgery is needed years later.
We often utilize technology called Image Guidance in the surgical suite. The Image Guidance system is like GPS for the sinuses. This device allows us to pinpoint the location of our instruments within that particular patient as we work during the surgical procedure. This allows the surgeon to have the greatest accuracy and location of anatomic structures during surgery. It has been a great advance in our field. Our practice was one of the first in the Midwest to start using this technology in about 1994.
Two Weeks Before Surgery
Do not take non-steroidal anti-inflammatory drugs (NSAIDs) for two weeks prior to surgery. Medications in this family include: aspirin, ibuprofen, Advil, Motrin, Aleve, naproxen, Celebrex and others. These medicines increase the risk of bleeding. Also, discontinue all homeopathic alternative medicines such as ginkgo biloba, garlic, fish oil, dong quai, feverfew or ginseng. These too may increase bleeding. Tylenol (acetaminophen) is not an NSAID, therefore, can be taken prior to surgery.
- You should anticipate frequent visits to our office for three to six weeks after surgery until healing is complete. The postoperative cleaning, (called sinus debridement), of your nasal/sinus area is a very important part of your care. This can help to prevent persistent or recurrent disease, and lessen the chance for adhesions or scar bands forming at the operative site.
- You can expect some bleeding for several days after the surgery and after each cleaning in the office. Do not snort the blood through your nose or blow your nose briskly as this will promote more bleeding for the first week.
- After two to three weeks, you will have thick, brown drainage (mucus and old blood) from your nose. This is normal.
- Avoid lifting more than 15 pounds, bending excessively, or straining for one to two weeks after surgery, since this may promote bleeding. Also, avoid vigorous exercise until healing is complete.
- Do not resume aspirin containing products or NSAIDs until this had been discussed with your surgeon along with your primary care physician and/or cardiologist.
- If you need to cough or sneeze, do so with an open mouth since this will prevent any excessive postoperative bleeding. Do not blow your nose until four to seven days after surgery.
- Use a saline nasal spray to cleanse your nose (Ocean Spray, Simply Saline, etc.) two to four times/day. This will help prevent large crusts forming in your sinuses. Steroid nasal sprays may also need to be continued in the postoperative healing period.
- If a persistent clear, watery drainage comes from your nose, you develop any visual changes, worsening headaches, or stiff neck please report this to us as soon as possible.
- Keeping your head elevated while sleeping will help to reduce the swelling within your nose.
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.