The Sinuses
The sinuses are cavities located in the forehead, cheeks and between the eyes. They have a lining that constantly produces mucus, which is moved out of the sinuses and toward the back of the nose by the action of microscopic hairs (cilia). Dust, allergens, bacteria and fungal spores that are inhaled are trapped in the mucus and usually carried out of the nose by this system, which is very similar to the clearance mechanism of the lungs.
Chronic sinusitis (properly called Rhinosinusitis) is inflammation of the sinus and nasal lining. It is a complex and variable disease and results from any or all of impaired mucus clearance, microorganisms (bacteria, fungi, viruses) and inflammation of the sinus lining.
Treatment of Sinusitis
Treatment is aimed at improving mucus clearance, removing microorganisms and reducing inflammation. Medical treatment is usually attempted first, with tablets, sprays and / or nasal washes. If this is unsuccessful, surgery may be recommended. Surgery is performed to:
- Remove obstructions to mucus clearance.
- Remove thick, infected mucus and other material from the sinuses.
- Open the sinuses so that after surgery nasal washes and other nasal medications can get into the sinuses.
Sinus surgery
Sinus surgery is performed using endoscopes placed through the nostril. Your surgeon will explain the procedure that will be performed in order to correct your problem.
A drill may be used to open the frontal sinuses more effectively – either each side individually (“Carolyn’s window” approach) or joining both sides to create a common opening (modified endoscopic Lothrop / Draf 3 procedure).
Endoscopic sinus surgery usually takes from one to three hours depending on the complexity of the operation.
Septal and turbinate surgery
Septoplasty (straightening the nasal septum) is often performed as part of sinus surgery to improve access to the sinuses and improve the nasal airway. Inferior turbinate reduction is often combined with sinus surgery to treat nasal blockage.
After surgery
Your surgeon will let you know if you can be discharged on the same day after surgery or whether you will need to remain in hospital overnight. Your nose will feel blocked and stuffy after surgery, as if you have a cold or a flu and you will get some blood and mucus from the nose, particularly over the first few days. Pain is not usually severe and generally managed with a combination of paracetamol and ibuprofen, with stronger pain relief if needed. Antibiotics and / or prednisone may also be prescribed if needed. In most cases soft silicone splints and sometimes sinus dressings will be left in the nose after surgery and follow up to remove these is usually 5 or 6 days after surgery in the clinic. You should avoid heavy lifting and strenuous exercise for 1-2 weeks after surgery – walking is fine from day one. Those with sedentary jobs can usually return to work after a week, for more strenuous work 2 weeks will be needed due to the risk of bleeding.
Nasal care
You will be provided with a FLO Sinus Care or FLO Postoperative kit to douche the nose. Nasal and sinus douching is essential after surgery to clear blood clot and mucus from the sinuses and nose. If blood clot is left in the sinus cavity, it can promote scarring, which can cause a poor surgical result.
Nasal douching is usually continued for a minimum of 6-8 weeks after the operation as it can take this long for the normal mucus clearance mechanisms to start functioning properly. In some cases, especially with nasal polyps, medications may be added to the douche, and this may need to continue long term.
Complications of surgery
- As with any anaesthetic or surgical procedure there are always risks of complications. Whilst the incidence of serious complications is very rare, it is important you are aware of them so you can discuss them with your surgery before your operation.
- Failure of the surgery - Depending on the nature of the disease which causes the problem in the first place, the underlying disease process may continue resulting in recurrence of symptoms. Usually this can be managed with medications but at times further surgery is necessary.
- Bleeding - Excessive bleeding may occur during the procedure. This obscures the view through the endoscope and on rare occasions can result in the surgery being stopped before it is completed. Very rarely, blood transfusion can be necessary.
- Some bleeding is normal postoperatively but occasionally heavy bleeding may require treatment with packing in the nose or returning to the operating theatre.
- Sense of smell - The sense of smell is often poor while the nose is blocked during the first weeks after surgery but then recovers. However, on very rare occasions the sense of smell can become permanently distorted or lost.
- Infection / septal haematoma - Should this occur, treatment with appropriate antibiotics will be given. If there is increasing pain and/or nasal blockage you must contact your surgeon immediately. Infection can occur in the sinuses, the tissues of the nose, or rarely a collection of blood can accumulate in the septum requiring drainage.
- Septal perforation - If septoplasty is performed as part of the procedure, occasionally a hole may develop through the septum. This often doesn't cause any symptoms, but if it does, surgical repair may be necessary.
- Postoperative scar formation or adhesions - In some cases scar formation or adhesions can form in the sinus cavity and cause recurrent symptoms. Occasionally this will require revision surgery to correct.
- CSF leak - Some sinus surgery takes place very close to the lining of the skull vault called the dura. This dura can sometimes be pierced resulting in leakage of cerebrospinal fluid into the nasal cavity. This complication rate is about 1 in 1000.
- Should the leak be seen at the time of operati surgeon will usually repair it immediately, however it may only be noticed after the operation when it will appear as clear fluid dripping from the nose. In the event this is noted after the operation, further surgery will be required to close the hole and so prevent the possibility of serious infection such as meningitis.
- Eye complications - Swelling and / or bruising of the eyelids is uncommon and will usually resolve within 7-10 days. Since endoscopic sinus surgery takes place very close to the eye socket it is possible to encounter the following complications.
- Damage to the tear duct. On rare occasions this can result in a watery eye. This may improve over time, however in some cases it may require an operation to repair. The risk of this complication is less than 1 in 100.
- Bleeding into the eye socket. An artery can bleed into the eye socket requiring emergency surgery to correct. The incidence is less than 1 in 1000.
- Damage to the eye muscles. This is an extremely rare complication which can result in double vision, which can be permanent.
- Damage to the optic nerve resulting in blindness. This is also extremely rare.
- Numbness or altered sensation.
- Numbness behind the front teeth is fairly common, but usually resolves over several months. Occasionally this can be permanent however.