Sinus Surgery

Sinus Surgery– Details-                                                                                                                                                                      Sinus surgery is done to remove nasal polyps and to treat chronic sinusitis .Following are the most frequently asked questions regarding Sinus surgery are- What is sinus surgery?

Sinuses are hollow cavities situated inside a human skull that are located  around the eyes and nose and within the anterior aspect of the face.

These cavities/sinuses help to make the skull lighter. They  have  the  function of  mucus production which  adds moisture to the nasal passages so  that  the  inspired  air  is  moistened before  entering the lungs. Dry  air  is  not  good  for  health  of the lungs. The mucus provides a protective layer to help keep out undesired particles like pollutants, dirt, and infectious organisms like  bacteria and  viruses.

Maxillary sinus  drains into the maxillary sinus ostium. All  other  sinuses ,the  frontal   ethmoid  sinuses  drain  into  the  maxillary sinus ostium. So  if  the  osteomeatal complex is  blocked, it  leads  to  fluid  accumulation in  all the  sinuses. So  functional endoscopic sinus surgery  is  a  procedure surgery that aims to open the pathways of the sinuses and clear blockages.In this  the  first  step  is uncinectomy  and  maxillary  sinus  ostium  widening, then

Anterior and posterior  ethmoidectomy, if  these  sinuses are diseased, then  frontal  recess widening if  there is  blockage  of the  frontal recess  and  SOS removable  of  pathologic tissue if  any  from the  frontal sinuses.  This is an option for people with ongoing and recurrent sinus infections, for people with abnormal sinus structure, or abnormal growths in the sinus which  do  not  respond to  conservative  line of treatment.Such people require sinus surgery.

An ENT specialist doctor will often attempt other treatments and procedures before resorting to surgery. If these don’t  provide relief  to  the  patient then  only  surgery may be carried out.

Sinus surgery is a brief procedure that has few complications.

Sinusitis is an infection in the nasal passages in which  there is  accumulation of  fluid, pathological  material in the  tissues which can cause pressure, headaches, a stuffy nose, and congestion.

The aim  of the functional endoscopic sinus  surgery is to remove whatever is blocking the drainage pathways of the sinuses. This may  be  accompanied by additional  procedures like –

Trimming of  Concha bullosa,

Septoplasty

Thermal  cauterization of  inferior turbinates

Removal of  ethmoid  polyps  if  any

Removal of tumors or growths blocking the nasal or sinus passage, if any

A person may require sinus surgery to treat a variety of issues like –

Sinusitis is the swelling ,inflammation of the nasal sinuses or passages also  called  called a sinus infection. Clinical features of sinusitis-

pressure around the nose, eyes, or forehead

a stuffy nose

nasal discharge

cough

congestion of head and headaches

 post-nasal drip

blocked ears or decrease in hearing

Nasal polyps are swellings of the nasal lining inside the nasal passages and sinuses.They arise  from  the  mucosa  lining  the  sinuses  and  nasal  cavities  They are variable in size .

Larger polyps or clusters result in obstruction to  airflow, hence   breathing issues and can affect  sense of smell.In some  cases  there is  total  loss  of  smell  sensation.  They can also block the  osteomeatal complex leading to infections ,accumulation of  fluid  pathological tissues in  sinuses.Such cases require sinus surgery.

Some people say that they have  no symptoms from nasal polyps. Clinical features of  nasal polyps include:

a blocked nose, leading to difficulty in breathing

a runny nose

recurrent sinusitis

post-nasal drip

a reduced sense of smell /total absence of smell or taste

facial pain

headaches

snoring

sleep apnea

Sinus surgery may also be required due to other infections, ongoing blockages, abnormal growths, and other issues that cause inflammation and  pathology in the nasal passages and sinuses.

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

FESS is carried out with an endoscope which is available  in  various  degrees  -0 degree  30 degrees, 70 degrees. By  degrees  we  mean  the  inclination  of vision of  the  scope  with the  axis of the scope. This is an illuminated, thin fiber-optic tube ,illumination  is  done  with  Led  light source.  The endoscope is inserted into the nose to reach the openings of the sinuses at  various stages of the surgery.

In  Functional endoscopic sinus surgery  the surgeon  with the  help  of  endoscope  uses  his  Instruments  to remove obstructive tissues and other blockages to clear the sinuses.

The entire procedure is carried out through the nostrils .No  external  incision  is  required. and leaves little to no scarring. Some swelling may occur, but it will disappears early.                                                                                                                                                                          Technique of Sinus Surgery-First a thorough routine nasal endoscopy is done .If there is significant nasal septum deviation ,it has to be corrected by doing Septoplasty.If the CTSCAN-PNS is showing involvement of the maxillary sinus,the uncinate process on the lateral nasal wall is identified and removed-Uncinectomy-By this the scope enters the maxillary sinus and pathology present in the maxillary sinus is removed by forceps.If the anterior and posterior ethmoid sinuses are showing involvement  on CTSCAN-PNS then anterior and posterior ethmoidectomy is done,if the Sphenoid sinus is showing involvement then opening is made in the anterior face of sphenoid sinus and disease present inside is removed.nasal packing is done with net cell and dressing given to patient.

An individual who has this surgery will usually only feel mild discomfort for a short period of time as  this  is  advanced  endoscopic  stitchless  procedure.In some  cases  it  can be  done  even under  local  anaesthesia.

FESS can be performed frequently. It can also be carried out on an outpatient basis.

Previously navigation system  was  used  mainly  by  neurosurgeons, but  nowadays  even  ENT  surgeons  have  started  using it .Of  course  lot of  presence of  mind  is  required  by the  operating  ENT  surgeon  as  at  times  the  navigation  system may  not  show  accurate  results.

Image-guided endoscopic surgery is a newer procedure that may be recommended for severe forms of sinus blockages or in  case of  individuals  who  had  been  operated  for  sinus  surgery. As  in the  previous  surgeries  important  landmarks  had been lost.

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.The position  of  his  instruments  is  shown  in  the  form off a red  dot  on  the  CT scan.  This is done using CT scans and infrared signals.

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

This procedure is more invasive and  is rarely  done  now a days. It  is  not  recommended  surgery  as  the  drainage  of  the  maxillary sinus  always  takes through the  maxillary  sinus  ostium only. So  in  case  of  osteomeatal  complex  block  procedure  of  choice  is  uncinectomy  and  maxillary  sinus  ostium  widening. Opening  in  the  anterior  aspect of  the  maxillary  sinus  which  is  done  in  Caldwell Luc is  of  no  use  at  all, as  drainage  of  maxillary  sinus  will  never  take  place  from  there.

After sinus surgery has taken place, nasal packing is  done  by  net cell to control bleeding.Net Cel  is  removed  after  24 hrs  and  patient  is  discharged  home.

Recovery periods  depends on the surgery performed and other factors such as age and general health. However, many people experience almost  no discomfort after sinus surgery. Most individuals can go home the same day as surgery but  it  is  advisable  to  let  the  patient  admitted  for  at  least  24 hrs  after  surgery, under  observation  for  bleeding, pain nausea  vomiting and  other  factors.

Post  discharge   prescription contains  analgesics, antibiotic ,antihistamnic ,antacids, nasal  decongestant  drops, Fluticasone  nasal  spray,.Alkaline  nasal  douches are  advised  by  syringing  without  needle  as  the  scabs  formed  due  to  surgery  should  fall  off  through  nose  or  by  post nasal  route  which  the  patient  can  spit  off. Alkaline  nasal  douches contain a  glass  of  water  which  is  boiled  and  cooled ,in  which  2 teaspoons of  sodium  chloride  and  two  teaspoons  of  household  baking  soda  is  used. All these things are required after sinus surgery. After the operation,  the  individual  experiences –

pain  over operated  field

nausea, vomiting,

sense  of  dryness  of  throat

mild  blood  stained  oozing, for  which  Pause, Ethamsylate should  be  given  to  the  patient

mild discomfort

fatigue

nasal congestion

People should closely follow their doctor’s instructions for aftercare and take all medications as prescribed,avoid any  trauma to  the  nose in  the  first  three weeks.  They may have to make changes in their daily routine for the first 2 weeks after surgery.They should  come  for  follow   5 days  from  the  day  of  discharge

Following  are the complications that can occur during sinus surgery –

Bleeding

Bleeding after surgery tends within the first 24 hours is  very  rare  if  the surgery  is  done  well. Mild  blood  stained  oozing  is  there  till some time  and  the  patient  is  asked  to  gently  mop it  in  between. This  oozing  can  also  be  stopped  by  giving Pause, Ethamsylate injections to  the  patient. However, it can sometimes occur later, after days or even weeks. which  is  very  rare  by  experiennced surgeons. If a clot develops within the bony partition between the nasal passages, commonly called the septum, then it must be removed under  general anaesthesia.

Intracranial complications

The septum attaches to the roof of the nose. This thin layer of bone may be damaged during sinus surgery. However, this is a very rare complication and  usually  does  not  happen  with  qualified and experienced ENT(Ear,nose,throat) surgeons.In order  that  this  should not happen, then  adequate  strip  of  septum  should  be  preserved by  the  ENT  surgeon  which  is  in  the  immediate  vicinity  of  the  skull  base so as  to  prevent  any  damage  and  CSF  rhinorrhoea.So sinus surgery has to be done with great care by the ENT surgeon.

If  CSF  rhinorrhoea  occurs  due  to  such  damage then the Cerebrospinal   fluid can leak into the nose and, in severe cases, can lead to an infection in the lining of the brain such as meningitis. While this issue is extremely rare, it is often identified  it  requires  an  urgent  neurosurgical  reference.

Although eye damage is rare, with  qualified and experienced ENT surgeons ,but  if  in  sinus  surgery  while  opening  the  frontal sinus  if  the  anterior  ethmoidal artery  is  damaged, then  it  can  retract causing  intraorbital  haemorrhage and  thus  blindness. Many  ENT surgeons fear  to  open  the  frontal sinuses due  to risk  of  damaging  the  anterior  ethmoidal  artery.So sinus surgery has some potential complications.Sinus surgery should be done only by qualified and experienced ENT surgeon.

If  the  lamina papyracea  is  damaged  during  surgery  then, bleeding  into  the  orbital region along  with  prolapse  of  fat  into  the  orbital  area  with  proptosis can  occur. Treatment  is  by  insertion  of  autologous  cartilage .

 There have also been rare reports of damage to the muscles that move the eye, which can lead to temporary or permanent double vision.(Diplopia). If  such  thing  occurs  Ophthalmologist opinion  should be sought  as  early as possible.

Other instances may lead to a change in how the tear ducts work, causing excessive tearing from  the  eyes. All  these  things  can  be  avoided  if  appropriate  care  is  taken  by  the  operating  ENT surgeon during sinus surgery.

Changes to a person’s voice

Sinuses affect the resonance of a person’s voice. A complication of sinus surgery can sometimes lead to a change in someone’s voice as  sinuses  contribute to  the  resonance  of  voice.

Loss of smell or taste

After sinus surgery, a person’s sense of smell usually improves due to the airflow being restored. However, it can worsen in rare cases depending on the extent of swelling or infection. This is often temporary but can be prolonged.Once  the  tissue  oedema  resolves which  usually  happens  in  a  period  of  few  days  after  surgery, the  sense of  smell also  improves.

Infection

 A person with sinusitis can develop other infections in the area of  surgery, as a result of surgery if apropriate aseptic precautions  are  not  taken, but  if  observed  and  intra -o higher  antibiotics  are  given, then  for  infection  to  occur  is  very  rare, even  if  it  occurs  ,it  can  be  tackled  by  higher  antibiotics.So antibiotics should be always given after sinus surgery.

Nasal issues

In rare cases if  due to surgery small amounts of scar tissue may develops in the nasal passage that will require another surgery  to remove it. Adhesions  can  develop  between  the  septum  and  the  turbinates, which  require another  surgery  to  release  it  with  surgical knife, placement  of  silastic  between the  turbinates and  the  septum, and  removal  of  silastic  after  few  days, once  the  purpose  of  silastic  is  over.

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

analgesics,antiinflammatory agents

steam  inhalations

avoiding  cold  drinks  ice-creams,

avoiding  drinking  cold  water

drinking  water  should  be  pretty hot

hot  water  gargles

drinking  hot  milk  with  turmeric and  sugar(in non-diabetics)

avoiding  citrus foods,

curd

highly spicy  foods.But in severe resistant cases sinus surgery is the only option.

But  if  these  things  give  only  temporary  relief  to  the  patient and  problems  recurr again and again , if  there  are  pathological changes  in  the  sinuses  with  blockage  of  the  osteomestal complex in  CT-SCAN -PNS-then Sinus  surgery  is  the  only  line  of  management. If  associated  Deviated nasal septum  is  there  ,then it  should be  corrected  by  Septoplasty  surgery  at  the  same  time  when  Sinus  surgery  is  done.

Any medical information published on this website should not be used for diagnosis and treatment .This  is  for  your  information. Whenever  you  are  suffering  from  any  disease or  disorder you  should  have  some  knowledge  about it, so  that  you respond  better  to  treatment.  Ultimate  diagnosis  and  treatment  should be  done  by  your  qualified and experienced ENT(Ear,nose,throat)  specialist doctor .

Prabha ENT clinic, plot no 345,Saigram colony, opposite Indoline furniture Ambad link road ,Ambad ,1 km from Pathardi phata Nashik ,422010,Maharashtra,India-Dr Sagar Rajkuwar (MS-ENT), Cel no- 7387590194,9892596635