Endoscopic sinus surgery (ESS) was initially developed during the 1980s and quickly replaced older more invasive forms of sinus surgery. It is still the mainstay for surgical treatment of many sinus problems, though in the past decade balloon sinus procedures have been developed for certain conditions.
ESS is performed entirely through the nostrils using a specialized telescope. No incisions are made through the skin or inside the mouth.
In general, the purpose of ESS is to widen the natural openings to the sinuses and clear out any infected mucus or debris trapped inside. The exact procedure performed depends on each individual patient and which sinuses are diseased.
We have 4 different sinuses on each side of the nose: the maxillary, ethmoid, frontal, and sphenoid sinuses.
The maxillary, frontal, and sphenoid sinuses are similar in that they are typically single large spaces which drain out of one opening. Thus, when I perform ESS on these particular sinuses, my goal is to identify, open, and widen the natural openings into the sinuses. Balloon sinuplasty is an option for the maxillary, frontal, and sphenoid sinuses.
The ethmoid sinuses are different: they are composed of many smaller spaces. The ethmoids appear similar to a beehive on CT scan- the drainage pathways are complex and there is not one single way out for mucus. As a result, surgery on the ethmoid sinuses requires actual removal of the diseased sinuses and the creation of one large cavity. Balloon sinuplasty cannot be used for ethmoid sinus disease. However, some studies have shown improvement in ethmoid sinus disease when balloon dilation is performed on the maxillary and frontal sinuses.
There are many reasons that patients might benefit from endoscopic sinus surgery. The most common reasons are 1. Chronic sinusitis which does not resolve with maximal medical therapy and 2. Recurrent acute sinusitis (more than 2-3 sinus infections per year). Other common and less common reasons are removal of nasal polyps, allergic fungal sinusitis, mucoceles (expanding trapped pockets of mucus), fungal balls, and others.
It is important to realize that ESS is generally not a 100% permanent cure for sinusitis. The surgery addresses anatomic problems that contribute to sinusitis (i.e. blocked sinus openings), but it does not get rid of underlying causes of inflammation like allergy or bacterial biofilms. Most patients who undergo ESS for proper reasons will improve significantly after surgery, though. They will generally have less of their typical sinus symptoms and get infections less often. Sometimes their symptoms will completely resolve.
As stated above, the exact surgery performed depends on each individual patient’s disease. A single sinus affected on one side only can be opened in as little as 10-15 minutes. Extensive disease and polyps in all the sinuses could take 2 hours or more to address completely. The surgery is performed under general anesthesia and is outpatient (i.e. you will go home the same day assuming there is no problem).
Endoscopic sinus surgery is safe in experienced hands but does carry a number of potentially serious risks because of the location of the sinuses.
The more common risks are typically the least dangerous: these include bleeding and scarring inside the nose. Severe bleeding is very rare. Scarring inside the nose can lead to the sinuses becoming blocked again and negating the improvement from the surgery. It is important to follow up regularly during the healing process to have your nose cleaned to prevent scar formation.
More serious risks of sinus surgery include damage to the eye/eye socket (including possible loss of vision) and leak of spinal fluid from around the brain. The side wall of the sinuses is a thin sheet of bone that covers the eye socket. The roof of the sinuses is the floor under the brain. There is a potential risk of entering either of these areas during sinus surgery. If this occurs, it can almost always be fixed as long as it is recognized. Fortunately, these serious complications are rare and occur well less than 1% of the time.
After sinus surgery, what should you expect? Typically there is a moderate amount of pain which improves within several days. I will give you a prescription for vicodin or another strong pain medication to use as needed during this time. I usually do not pack the nose after ESS unless I am concerned about bleeding. Some bloody oozing for the first day or two is expected. You can tape gauze under your nose and change as needed.
Depending on the patient, I may or may not prescribe antibiotics or steroids to take either the week before or after surgery (or both). All patients should use a sinus rinse 2-3 times a day for at least a week after sinus surgery to help the healing process. Patients who use a nasal steroid spray such as flonase or nasonex should stop this medication for 1 week after surgery and then can restart the spray.
Patients should avoid nose blowing, straining, heavy lifting (more than 10 pounds), or strenuous exercise for 1 week after surgery. Avoid driving until off prescription pain medications for 24 hours. Patients can return to work when they want but must follow the above instructions while at work and at home. There are no absolute diet restrictions, but in general it’s best to avoid alcoholic drinks and very hot temperature liquids for 2 days after surgery as these can increase bleeding risk.
I usually see patients back in the office 5-7 days after surgery and then again 2-3 weeks later. I will clean out any crusting inside the nose at these appointments to help make sure everything heals well.
Call (512) 550-0321 if you have any questions or to schedule an appointment!