Endoscopic Sinus Surgery
What is sinus surgery?
Sinus surgery, sometimes called functional endoscopic sinus surgery (FESS), is reserved for a small percentage of patients who need more than medical therapy to achieve optimal control over their sinus disease. All sinuses have a natural opening where mucus is drained from the sinus into the nose. In patients with sinusitis, the lining of the sinuses is inflamed and swollen and do not fully allow mucus to drain out of the natural. As a result, patients with chronic sinusitis often have trapped mucus in their sinuses which can lead to further inflammation and infection. Sinus surgery involves widening these natural openings to improve mucus clearance from the sinuses. The surgery is done with the aid of a small telescope placed inside the nose so the surgeon can delicately dissect the thin bone and mucosa within the nose and sinuses. No external excisions are required and there are no visible scars after sinus surgery. Most of the time, this surgery is an outpatient procedure done under general anesthesia and you are allowed to go home on the day of surgery.
In addition to sinus surgery, some patients may also need a septoplasty (a procedure to straighten the septum – a structure which divides the inside of the nose into the left and right side) and/or an inferior turbinate reduction (a procedure which reduces the size of the inferior turbinates – bones which line the inside of the nose – in order to allow more air into the nose and sinuses). Depending on your symptoms and what the inside of your nose looks like, your surgeon may also recommend these procedures along with your sinus surgery.
Different levels of sinus surgery
Depending on the extent of your sinus disease, your sinus surgeon may need to open all the sinuses or only open some of the sinuses. Before surgery, your sinus doctor will discuss what symptoms you are having and go over your CT scan to make a surgical plan that best fits your disease and circumstances. To allow your sinuses to drain and get good airflow into your nose, your sinus doctor may also have to straighten your septum and reduce the size of your inferior turbinates during your sinus surgery. Talk to your doctor before surgery to understand your personalized surgical plan.
How to prepare for sinus surgery
In preparation for your surgery, your physician may prescribe preoperative medications to optimize the condition of your sinuses for surgery. The medications may include antibiotics and/or oral steroids. Please be sure to start any preoperative medications on the appropriate day and adhere closely to the prescription.
In addition, you should avoid taking the following medications for at least 7 days prior to surgery: Aspirin, Ibuprofen (Motrin/Advil), Naproxen (Aleve), other non-steroidal anti-inflammatories (NSAIDS), Vitamin E (multivitamin is OK), gingko biloba, garlic (tablets), and ginseng. These medications can thin the blood and create excessive bleeding. Tylenol is safe and may be taken anytime up to the day of surgery. St. John’s wort should also be avoided for 7 days prior to surgery because of possible interactions with anesthesia medications. If you take any blood thinners, such as Coumadin or Plavix, please discuss discontinuation of this medication with your surgeon.
If you smoke, it is critical that you stop smoking for at least three weeks prior to surgery, and at least four weeks after surgery. Smoking can contribute to scarring, poor healing, and failure of the operation. Your primary care physician can direct you to resources for smoking cessation.
Finally, it is important to inform your primary care physician or other specialists (such as your cardiologist, pulmonologist, etc.) that you are planning to have sinus surgery. Your primary care doctor or other specialists can help to clear you medically for surgery. We will make every effort to keep your primary care physician informed regarding your medical status both before and after your surgery.
What happens after sinus surgery
You can expect mild bleeding for 1-2 days after surgery and a general sense of fatigue for 1-2 weeks after surgery. In general, pain can be successfully controlled with narcotic or non-narcotic medications.
For the first week following surgery you should avoid blowing your nose. In addition, you should not bend, strain, or lift more than 20 lbs. during the first week. Light walking and regular household activities are acceptable anytime after surgery. You may resume exercise at 50% intensity after one week and at full intensity after two weeks. You should plan on taking one week off from work and ideally have a half-day planned for your first day back.
You will have a series of postoperative visits that are critical for a successful outcome. At each visit your doctor will perform a procedure called nasal endoscopy to check how the sinuses are healing. An additional procedure called debridement may be necessary in order to clean blood from the sinuses and prevent early scar tissue formation.
What are the risks of surgery?
As with any surgical procedure, sinus surgery has associated risks. Although the chance of a complication occurring are very small, it is important that you understand the potential complications and ask your surgeon about any concerns you may have.
Bleeding: Most sinus surgery involves some degree of blood loss, which is generally well tolerated by the patient. However, on occasion, significant bleeding may require termination of the procedure. Blood transfusion is rarely necessary and is given only in an emergency.
Recurrence of disease: Although endoscopic sinus surgery provides significant symptomatic benefits for the vast majority of patients, surgery is not a cure for sinusitis. Therefore, you can expect to continue with your sinus medications even after successful sinus surgery, although in general your requirements for such medications should be lessened. In some instances, additional “touch-up” or revision surgery may be necessary to optimize your surgical outcome.
Spinal fluid leak: Because the sinuses are located near the brain, there is a rare chance of creating a leak of spinal fluid (the fluid lining the brain) or injuring the brain. Should the rare complication of a spinal fluid leak occur, it may create a potential pathway for infection, which could result in meningitis. If a spinal fluid leak were to occur, it would require surgical closure and hospitalization.
Visual problems: Visual loss has been reported after sinus surgery due to injury to the eye or optic nerve. The potential for recovery in such cases is not good. Fortunately, such a complication is extremely rare. Injury to the eye muscles may result in double vision. Persistent tearing of the eye is another possible complication. Tearing problems usually resolve on their own but occasionally require additional surgery.
Other risks: Other uncommon risks of surgery include alteration of sense of smell or taste; persistence and/or worsening of sinus symptoms and facial pain; change in the resonance or quality of the voice; and swelling or bruising of the area around the eye.
Some patients have a crooked nasal septum (“deviated septum”) that needs to be corrected at the time of surgery through a short procedure called septoplasty. This procedure is performed through a small hidden incision and involves dissolvable stitches that are hidden in the nostril area. If you require septoplasty, there are additional risks associated with this procedure. The primary risks are bleeding or infection in the area of the septum; numbness of the front teeth; the development of a hole through the septum (septal perforation); brain fluid leak; or recurrence of septal deviation. There is a very small risk that such occurrences could alter the external appearance of the nose.
What are non-surgical options?
In addition to the standard medical therapy of topical intranasal steroids and salt water rinses of the nose or sinus surgery, there are also other options to treat CRS. Based on your particular disease and unique needs and circumstances, other treatments may be right for you. Talk to your sinus doctor about what other treatments may fit your personalized needs.
If you have allergies, this could be making your sinus disease worse. Patients may need to treat their allergies with either medications or immunotherapy to improve their allergies. Immunotherapy is a process where patients are desensitized to the particular allergen they are allergic to with either allergy shots or allergy drops. When a patient’s allergies are well controlled, their sinus disease often improves.
If you have asthma, we know that treating your asthma can help improve your sinus disease. Likewise, treating your sinus disease can also improve your asthma.
Biologic medications are a class of medications that are new for the treatment of sinus disease. This class of medications has been used for many years to treat many other conditions such as asthma, eczema and rheumatoid arthritis. Dupixent (generic – dupilumab) was approved to treat chronic rhinosinusitis patients who have nasal polyps in July 2019. This medication has been shown to improve patients’ quality of life and cause a decrease in nasal polyp size. Dupixent is a medication that requires injection once a month which can be done by the patient in their home once they have learned how to do the injection at the doctor’s office.
Balloon sinuoplaty is another option for treating sinus disease. This can be done in the office and is a procedure where the natural opening of the sinus is slightly widened. This procedure can be helpful in certain conditions. Talk to your sinus doctor if balloon sinuoplasty is right for you.