Over the past few decades, sinus surgery has evolved significantly. It was once performed through external incisions. It often required extensive nasal packing (i.e. gauze or other material placed in the nose to control bleeding after surgery). Significant pain and a long recovery were common.
Advances in technology have allowed sinus surgery to be performed entirely through the nose. Incisions on the face or in the mouth are rare. One important development is the nasal endoscope which is a small, lighted metal telescope placed into the nostril. The endoscope allows the surgeon to see inside the nose and sinuses. Today, endoscopic sinus surgery is typically done with minimal nasal packing, little pain, and short recovery times.
Functional Endoscopic Sinus Surgery is a minimally invasive form of sinus surgery using small, rigid nasal endoscopes and specialized instruments to open the sinuses. The development of fiberoptic nasal endoscopes in the 1950s and the subsequent refinement of surgical techniques in the 1970s have led to significant advancements in the surgical treatment of patients who suffer from sinusitis. Endoscopic sinus surgery may be indicated in patients who are unable to obtain and maintain good sinus health without the use of medication or for those who have recurrent episodes of sinusitis caused by anatomic narrowing of the sinus openings. Endoscopic sinus surgery may also be indicated for the removal of nasal polyps or certain types of nasal tumors. Your symptoms, examination, and CT scan will determine which sinuses require opening. Sometimes during sinus surgery, the nasal septum, which divides the two sides of the nose, is also straightened. The turbinates, which filter and moisten air inside the nose, may also require surgery.
Endoscopic sinus surgery has some advantages over traditional open sinus procedures. The surgery is almost always performed entirely through the nostrils, resulting in no visible scars on the face. There is generally less tissue resection, resulting in faster healing and reduced postoperative pain and bleeding. Nasal packing is rarely used. In most cases, sinus surgery is performed as an outpatient procedure.
Functional Endoscopic Sinus Surgery
Why Is Functional Endoscopic Sinus Surgery (FESS) Performed?
The most common reason for doing sinus surgery is chronic sinusitis or rhinosinusitis. Chronic sinusitis is a term for inflammation (swelling) of the sinuses. Chronic means that the inflammation has been present for at least 3 months. The inflammation can be caused by infection, allergies, irritants, and many other things. Many times, we do not know exactly why patients have chronic sinusitis.
Chronic sinusitis, serious infections, and nasal polyps are reasons for sinus surgery. Nasal polyps are a sign of severe inflammation. Each individual case is different. Your sinus surgeon will determine if surgery is the best choice for your nasal/sinus problem.
What Treatments Should Be Tried Before Endoscopic Sinus Surgery?
Sinus surgery may be recommended when symptoms of sinus inflammation and infection persist despite proper medical treatment. Experts generally agree that most patients should be treated with appropriate antibiotics, as well as a course of saline irrigations and topical nasal steroids, before proceeding to surgery. It is essential to recognize that saline irrigations and steroid sprays require time to take effect and should be used daily for at least 3-4 weeks.
Patients with polyps may also benefit from a short course of oral steroids, although it is important to discuss the risks and benefits with your physician first. Other medications, like topical or oral decongestants, can be used every now and then for nasal stuffiness, but should not be used regularly.
Functional Endoscopic Sinus surgery should only become an option if you are unable to obtain and maintain good sinus health without the use of antibiotics.
What Are The Benefits of Endoscopic Sinus Surgery?
When medicines fail to control sinus problems, functional endoscopic sinus surgery may be helpful. There are several goals of sinus surgery. The main goal is to improve drainage by widening the natural openings of the sinuses. Infected mucus and polyps, if present, are removed. Creating larger sinus openings also allows topical medicines such as steroids to penetrate deeper and control inflammation and swelling. Sinus surgery allows medicine to work more efficiently and effectively.
It is very important to remember that chronic sinusitis is a chronic problem. Surgery has been shown to be very helpful in controlling symptoms and improving quality of life, but in most cases, it is not a “cure-all". Surgery is done in addition to, and not instead of, medical treatment of the sinuses. Continuing medical treatment after surgery is crucial for achieving optimal outcomes. On a practical level, for most patients, this means rinsing daily (or more!) with high-volume saline and using topical steroids and other medications consistently and as prescribed.
Does Anything Need To Be Done In Preparation For My Endoscopic Sinus Surgery?
It is recommended and necessary that patients avoid any medications, traditional and nontraditional, that may lead to bleeding, such as NSAIDs (ibuprofen), aspirin, and blood thinners for 7 – 14 days before surgery. In addition, supplements like vitamin E, garlic, ginger, ginkgo, and ginseng may increase the risk of bleeding; therefore, stopping them 7 to 14 days before surgery is required. Some patients may be asked to take antibiotics and/or steroids prior to sinus surgery. If you have any questions about which medications you should or should not take, you must ask your surgeon. Aspirin and other blood thinners should never be stopped without checking with the physician who prescribed the medication.
How Is Functional Endoscopic Sinus Surgery Performed?
Functional Endoscopic Sinus Surgery (FESS) is performed in an operating room under general anesthesia. Special surgical tools are used to gently remove diseased tissue and enlarge openings into the sinuses.
In some cases, your surgeon may also use “image-guided navigation”, in which special instruments are connected to your pre-operative CT scan and give live, real-time confirmation of important anatomic landmarks.
What Is the Recovery After Functional Endoscopic Sinus Surgery?
Many people do not report much pain after sinus surgery, but every patient is different. Depending on the details of your surgery, you may be prescribed stronger pain medicine, although often over-the-counter acetaminophen (Tylenol) is enough to control minor discomfort. For most patients, pain, congestion, and drainage improves after the first few days. Mild symptoms sometimes linger for several weeks after the surgery.
It is important to remember that control of sinus inflammation requires good, long-term medical management, including after surgery. Your surgeon will place you on medications after surgery and will see you for follow-up. Saline rinses, steroids, and antibiotics are common and should be used as prescribed.
Your surgeon will provide specific instructions as to what activities are allowed and what must be avoided. In general, excessive pressure to the head should be avoided. Instructions commonly include not blowing the nose, avoiding bending over and lifting heavy weights, keeping the head elevated, and adhering to light activity.
Will Functional Endoscopic Sinus Surgery Improve My Symptoms?
Most patients who have functional endoscopic sinus surgery do very well, with significant improvement in their symptoms and quality of life. But sinus surgery is not a “cure-all”. Good use of prescribed medications and regular post-operative care is extremely important to having the best possible outcomes.
What Are the Potential Complications of Functional Endoscopic Sinus Surgery?
Complications of sinus surgery are rare and include bleeding, scarring in the nose, failure to improve, and further surgery. Patients with certain types of sinusitis, including those with severe polyps, cystic fibrosis, aspirin-exacerbated respiratory disease, and allergic fungal sinusitis, as well as those with severe asthma and a history of prior sinus surgery, are more likely to require a revision procedure. The most serious complications of sinus surgery relate to damage to important structures around the sinuses, including the eye and brain. Although extremely rare, these can include vision loss, brain injury, and CSF leak. If you are uncomfortable with the risks of sinus surgery, it is important that you discuss this with your surgeon.
What Are Alternatives to Functional Endoscopic Sinus Surgery?
Live with it, do nothing, or continue medical therapy (antibiotics, nasal steroid sprays, oral steroids) are options, but disease control may be difficult without surgery.
Image Guided Navigation
Image-guided navigation is essentially like GPS (Global Positioning System) systems for the anatomy of your head. This technology has been a significant advancement in the field of functional endoscopic sinus surgery. Through image guidance, the CT scan provides the map for the system, and a computer constantly calculates the position of special trackable sinus instruments in relation to a patient’s sinus anatomy. This is helpful to your surgeon as they navigate close to structures such as the eye, brain, and optic nerve that surround the sinus cavities.
For more information on nasal and sinus surgery and to explore your treatment options, make an appointment to speak with our sinus specialist about the next steps towards your better sinus health.
While image guidance has been increasingly used in sinus surgery, it may not be required in all cases. Some types of cases that image guidance may be particularly useful are in cases of difficult and/or unusual sinus anatomy, patients with a history of previous sinus surgery, and/or nasal polyps.
Septoplasty
A septoplasty is a surgical procedure to correct a deviated septum. The nasal septum is made of cartilage and bone and divides the nasal cavity into two sides. Sometimes the nasal septum is crooked, and a portion of it may block the nasal airway. This is referred to as a “deviated septum.” The most common reason for recommending a septoplasty is for relief of nasal obstruction, although it may be recommended for other select causes as well. Septoplasty may be recommended alone or in combination with other procedures such as inferior turbinate reduction or endoscopic sinus surgery.
Turbinate Reduction
Turbinates are structures on the side walls of the inside of the nose that are made of bone and soft tissue. They warm and humidify the air as it passes through the nasal passages. Sometimes, the inferior turbinates can become swollen and enlarged, causing obstruction of airflow through the nose. The swelling can sometimes be reduced by the use of medications such as topical nasal steroid sprays or other allergy medications. If they remain enlarged and continue to cause nasal obstruction, a patient may be a candidate to consider a procedure to reduce the size of the inferior turbinates.
What Is “Sinuplasty” (A.K.A Balloon Sinuplasty or Balloon Dilation)?
“Sinuplasty” refers to a procedure to dilate the sinus openings with a balloon. Sinuplasty may be a less invasive alternative to FESS in certain situations, but it is not for correcting structural issues like a deviated septum. It is important to talk with your surgeon to determine the best option to treat your sinus disease.
Sinus Anatomy
Most people have four sinuses on each side of their face, totaling eight sinuses. These are the maxillary, ethmoid, sphenoid, and frontal sinuses. The maxillary sinuses are in your cheek. The ethmoid sinuses are between your eyes. The sphenoid sinuses are almost exactly in the center of your head. Finally, the frontal sinuses are in your forehead. Sinusitis may affect some or all of your sinuses.
The nose is divided into two sides by the nasal septum. The nose also has turbinates, which filter and moisten air inside the nose.