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Sinus Surgery

The Sinuses

sinus

The sinuses are cavities in the facial part of the skull.  Above the eyes are the frontal sinuses. Between the eyes are the ethmoid sinuses. In the cheeks are the maxillary sinuses.  The sphenoid sinus is in the centre of the head.  Normally the sinuses are lined by thin mucus-secreting tissue.  When healthy the sinuses are filled with air.  If mucus collects excessively in a sinus there is a tendency for the sinuses to become inflamed –this is sinusitis.

In the past sinuses were “scraped out” – a rough and unphysiological approach that often failed.

Recently it has been realised that the majority of sinus drainage and aeration is through the front centimetre of the ethmoid sinuses.  Removing blockage in just this area will allow the larger frontal and maxillary sinuses to drain and aerate.  Using high resolution CT scans we image the area before surgery and then use these scans as a “roadmap” during surgery. The new endoscopes (thin brightly illuminated magnifying telescopes) allow us to readily see the diseased tissue.  FES surgery is more precise and minimally invasive.  It can be performed without post operative nasal packing.

Symptoms of sinus disease may include facial pain or pressure, difficulty in breathing through the nose, a persistent bad smell in the nose, copious discharge either blown out or as post nasal drip.  However all of these symptoms can occur for other reasons.  Sinusitis is diagnosed by sound medical assessment, endoscopy in the rooms and CT scanning.

The Operation – Endoscopic Sinus Surgery

Sinus surgery is appropriate for people who have failed intensive medical treatment.

Endoscopic surgery takes around one hour and is performed under general anaesthesia and usually requiring one night in hospital.  Warning!  Patients are cancelled for two main reasons.  If you take Aspirin or Nurofen  products in the two weeks prior to surgery you will bleed.  Also if you forget to bring in your scans the surgeon has no “roadmap”.  Both of these can be dangerous situations.

Following the surgery expect some bloodstained discharge for several days.  The key to a good recovery and a clean wound is douche, douche, and douche!  At least six times a day. The more you douche the faster the sinuses heal.

THE NOSE SHOULD NOT BE BLOWN FOR SEVEN DAYS.  You could cause bruising and swelling around the eyes if you do blow your nose too early.  Normally there is no external sign that the surgery has been performed compared with the old fashioned sinus surgery. Expect to take two weeks off work.  You will be tired from the anaesthetic.

Expect post nasal discharge of increased amounts for up to six weeks.  Douching will help to clear this so continue to douche six times a day for six weeks.

Headaches are often experienced in the second and third weeks. These are often due to plugs of crusted mucus so douche more frequently in this period.  However if you do develop a foul smell in your nose or consistently green or yellow discharge along with the headaches, contact Dr Dunlop as this signifies infection.  You will need antibiotic therapy such as Keflex or Augmentin and sometimes Prednisone.

Complications are infrequent but include –

  • Infection
  • Bleeding
  • Bruising and swelling around the eyes (rare with  modern surgery)
  • Adhesions – requiring division if they impair sinus drainage and ventilation.  This may mean revision surgery is required
  • Blocked sensation and tinnitus in the ears.  This can take weeks to settle and is due to eustachian tube blockage.
  • An increased perception of post nasal discharge
  • A tearful eye – rare and usually temporary
  • Double vision or loss of vision – extremely rare
  • Leakage of the fluid surrounding the brain (CSF) which can possibly lead to meningitis and brain abscesses.  Sometimes these leaks are self–sealing.  Others require repair which can also be done endoscopically – rare
  • Loss of sense of smell – rare

A small minority of patients will require surgery to open the sphenoid sinus.  Again it is extremely rare but damage to the vessel in its back wall can lead to haemorrhage and stroke.

Two percent of people have worsening of sinusitis.

Expected Outcomes

Overall endoscopic sinus surgery is 5 times safer than the earlier external techniques involving the use of the headlight.  Also the success rates are far greater. In a large British study 78% regarded themselves as improved with an additional 9% feeling cured.  11% felt unchanged and 2% felt worse.  German studies report similar findings.  Most symptoms are improved though the most dramatic effect is on nasal obstruction (92%) and facial pain (86%).

Slower progress is made by those people with chest disease.  The germs in the chest can seed the sinuses causing recurrent sinusitis though this is less likely once the sinuses have been “opened out”.  Some patients will need to be reviewed by a chest physician.  Similarly, fungal infection can cause sinusitis resistant to surgical treatment.  These patients will be sent on to an immunologist for specific anti-fungal therapy.

Smokers with Sinusitis will never be cured by surgery as smoking causes secretions to pool in the sinuses leaving smokers prone to infection.

Patients with hayfever or allergy should notice fewer sinus infections (pain and coloured discharge) following FES surgery but the sensation of a blocked nose due to allergy will not change.  They will still need nasal steroid sprays or antihistamines to achieve a good nasal airway.

Overall the vast majority of patients are highly satisfied with modern sinus surgery as there is a minimal level of discomfort at the time of surgery and a high degree of satisfaction with outcome after six weeks of healing.

Lund V J, Mackay 1  Outcome assessment of endoscopic sinus surgery.  Journal of the Royal Society of Medicine Volume 87 February 1984, 70-72