Endoscopic Sinus Surgery
by Dr. Christopher Chang, last modified on
In a nutshell, endoscopic sinus surgery is when the natural openings of the sinuses into your nasal cavity are enlarged (to read more about balloon sinuplasty, click here). If any diseased mucosa like nasal polyps or pus accumulation are present, these are removed as well. The surgery itself is all done via small cameras so that there are no incisions on the face. It is not usual that a patient has any bruising, swelling, black eyes, or any other facial appearance changes after surgery. Most patients are surprised by how little pain there is afterwards.
Patients who are candidates for sinus surgery include:
• Chronic Sinusitis - A sinus infection that just will not go away in spite of several courses of antibiotics, ideally culture-directed. Studies include an abnormal CT Sinus scan and allergy testing to determine if the sinus infection may be allergy driven. Immunological studies may or may not be obtained as well.
• Recurrent Acute Sinusitis - Multiple discrete sinus infections per year (more than 4 annually) of which at least one has been documented on CT Sinus scan and/or via nasal endoscopy. Ideally, antibiotics tried should include one that has been culture-directed. Patient has also been tried and failed to respond with allergy treatment. Immunological studies are warranted to evalute for any immunodeficiency. [Link]
• Nasal Polyps - Sinus symptoms due to polyps that may fill both the nasal and sinus cavities leading to symptoms of congestion, obstruction, sinusitis, and loss of smell. Nasal polyp presence is confirmed on both CT Sinus scan as well as nasal endoscopy.
• Sino-Nasal Mass - Finally, the last category is a yet undefined mass which includes cancer.
There is often the mistaken belief that sinus surgery prevents sinus infections. This is NOT directly true. Rather, by enlarging the natural sinus openings, there is less chance of clogging which often leads to persistent sinus infections. The natural openings of your sinuses are only several millimeters in size and it doesn't take much for them to get swollen shut. Once the natural openings of your sinuses are enlarged through sinus surgery, there is less risk of blockage. If sinus infections occur, they readily drain and are cleared quickly. Also, sinus surgery is often just a tool that helps long-term medications work more effectively. Watch video explaining this further.
SO, most patients experience a decrease in frequency and severity of sinus infections after sinus surgery.
The other benefits of sinus surgery are that by having large sinus openings, saline sinus flushes work much better and your surgeon is now able to directly visualize the sinus cavities using an endoscope to monitor for sinus disease. Our office recommends regular use of saline flushes both before and after sinus surgery. We typically suggest using the Neilmed sinus rinse kit. Watch video to see how sinuses rinses are performed.
The other benefit of sinus surgery is that one can now add medications and antibiotics to the sinus rinse to treat all future sinus infections before taking any oral drugs. A medicated sinus rinse is basically delivering drugs directly to where the problem is rather than via the stomach. Watch video on this type of treatment here! Although medicated sinus rinses can be performed without having had sinus surgery in the past, drug delivery is not as effective given the sinus openings are too small for the rinse to effectively enter the sinus cavities. Common drugs often added to sinus rinses include, betadine, mupirocin, ioRinse, gentamycin, budesonide, etc.
There ARE risks with sinus surgery. The most common is a nosebleed. As such, it is not uncommon to have packing placed in the nose after sinus surgery. Depending on your surgeon, nasal packing may be placed only <10% of the time. If nasal polyps are present, the percentage increases.
Other theoretical risks include eye/vision damage as the eyeball is right next to the sinus cavities separated only by a thin wall of bone. The other risk is the potential for a cerebrospinal fluid leak ("brain" fluid leakage). This particular risk occurs when the roof of the nasal cavity sustains a small fracture allowing the fluid around the brain to leak into the nose much like a leaky roof after a rainstorm. Why could this happen? Remember that the floor of the brain case is also the roof of your nose.
Regardless of the risk, they are all correctable. Read our consent form that we have all patients sign prior to sinus surgery.
There is technology to decrease the risk of complications known as 3D Image-Guided Sinus Surgery. The technology used at Fauquier ENT is called BrainLAB. Think of this high technology as GPS for the surgeon to safely navigate around your sinus cavities. Watch a video demonstrating this technology below.
When investigating what may be causing a given person's sinus pressure/pain, a CT scan of the sinus is often ordered. The reason for the CT scan is to first of all, see if the symptoms are indeed truly coming from an infection as well as to see if there are any anatomic causes of sinus obstruction including a deviated septum that makes a person more prone to sinus infections. Turbinate hypertrophy also may play a role in a person's sino-nasal symptoms. A CT scan of the sinus is ABSOLUTELY necessary prior to any type of sinus surgery.
As most insurances will only pay to have ONE CT scan of the sinuses done in a given period of time, it may be worthwhile to request your doctor to get a CT sinus BrainLAB protocol so that IF surgery is needed, one can use the image guidance technology stated above. All too often, we encounter patients who already had a CT sinus done (without Brainlab protocol) who require sinus surgery, but because a CT was already done, insurance will not pay for another CT to be done with the BrainLAB protocol. In this scenario, the patient can either proceed with sinus surgery without using image guidance or wait 6-12 months to get another CT scan done with Brainlab protocol. One can always pay out-of-pocket for another CT sinus with BrainLAB if insurance denies instead of waiting 6-12 months.
Post-op instructions we give all our patients after sinus surgery can be read here.
Dr. Chang was quoted in a newspaper regarding this technology.
Video of portraying this technology shown below. If you are unable to view, click here.
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