Endoscopic Sinus Surgery
Marc Dubin, MD
With recent advances in technology, including the nasal endoscope, sinus surgery is now commonly performed entirely through the nose, without face or mouth incisions. The nasal endoscope is a small, lighted metal telescope placed into the nostril. The endoscope allows the surgeon to see inside the nose and sinuses, usually with a special video camera attached to the endoscope. Today, endoscopic sinus surgery is typically done with minimal nasal packing, mild pain, and short recovery times.
Why is endoscopic sinus surgery performed?
The most common reason for doing endoscopic sinus surgery is “chronic rhinosinusitis”, or more commonly “chronic sinusitis”. Chronic rhinosinusitis is a general term for inflammation (swelling) of the nose and sinuses that does not improve sufficiently with medical treatment. Chronic means that the inflammation remains in the nose and sinuses and does not go away over time (usually for at least 3 months). Infection, nasal polyps (non-cancerous swelling of the nasal/sinus lining), allergies or irritants, and other things may cause this inflammation of the nose and sinuses. Often, we do not know exactly why patients have chronic rhinosinusitis or chronic sinusitis.
Less common reasons to have sinus surgery may include: recurrent infections (meaning the infections go away with medicines but return very quickly), sinus infections that spread to the eye, face or brain, nasal polyps (See Figure, black arrows), impaired sense of smell, tumors of the nasal and sinus cavities (cancerous or non-cancerous growths), leaking brain fluid into the nose, tear duct blockage, and others. Additionally, recent advances in endoscopic sinus surgery allow your sinus surgeon to reach areas of the brain and pituitary gland for neurosurgeons, or to the orbits (eye sockets) for certain ophthalmology procedures. Each individual case is different. Your sinus surgeon will determine if endoscopic sinus surgery is the best choice for your nasal/sinus problem.
What treatments should be tried before endoscopic sinus surgery?
Before having endoscopic sinus surgery, patients should talk with their physicians to make sure that all reasonable medical treatments have been attempted. This list of medications that could potentially treat sinusitis is quite long. These medications include both prescription and over-the-counter treatments located at your local pharmacy. For acute sinusitis (an infection that usually occurs after a cold and lasts less than four weeks), antibiotics are the main treatment. In addition, nasal saline rinses or sprays may be used along with antibiotics. While nasal decongestant sprays (pseudoephedrine, oxymetazoline) can be used to treat nasal stuffiness, they should not be used longer than three days. With long-term use of nasal decongestant sprays, the nose can become dependent on them, and the nasal stuffiness could worsen. In addition, people who have high blood pressure, glaucoma, urinary retention, heart disease, and heart beat irregularities should consult their doctor before using decongestants because these medications can cause additional problems in these cases.
If a sinus infection or inflammation lasts beyond four weeks and becomes a more chronic illness, treatments may change. Antibiotics may be used for longer than a typical 10-14 day course. Nasal steroid sprays sprayed in the nose and oral steroids taken by mouth may also be used to decrease inflammation. Your physician may order a CT (“cat”) scan of your sinuses. A culture of sinus mucus may be done in the physician’s office to help choose the appropriate antibiotic to treat your sinuses. Allergy medications (oral antihistamines, nasal antihistamine sprays, allergy shots) have a role in treating allergy, which may also lead to nasal swelling. If someone does not have allergies, these allergy treatments will not significantly add to the medical treatment.
What are the benefits of endoscopic sinus surgery?
If medical treatments have not been successful in improving your sinus symptoms, endoscopic sinus surgery may be helpful. The main goal of sinus surgery is to improve the drainage pathway of the sinuses. By widening the natural drainage pathway of the unhealthy sinuses, sinus infections should be reduced. Patients with obstruction or blockage of their sinuses due to their sinus anatomy do very well with sinus surgery. Many patients also have a problem with inflammation (swelling) of the sinus lining (mucous membrane). Patients with mucous membrane disease also usually improve with sinus surgery because creating the larger sinus opening will allow better sinus drainage and more rinses/medication to get into the sinuses and help treat the diseased lining. One of the most important benefits of surgery is the ability to deliver medications (sprays, rinses, nebulized drugs) to the lining of the sinuses after they have been opened. Therefore, sinus surgery is done in addition to, and is not a replacement for, proper medical treatment of the sinuses. It is important to note that if you are one of the patients who have diseased mucous membranes or form nasal polyps, no amount of surgery can change this fact. For many patients, surgery may not be a cure for sinusitis but is one of the many critical steps in managing sinus disease.
Does anything need to be done in preparation for my endoscopic sinus surgery?
Most surgeons recommend that patients avoid any medications that may lead to bleeding, such as aspirin and ibuprofen products. In addition, certain vitamins, herbal remedies, and spices including vitamin E, garlic, ginger, gingko, and ginseng may increase the risk of bleeding. Some patients may be asked to take antibiotics and/or steroids prior to sinus surgery. This will vary greatly from patient to patient and surgeon to surgeon, so if you have any questions about which medications you should or should not take, you must ask your surgeon. Most surgeons will provide a list of medications for their patients to avoid prior to surgery.
How is endoscopic sinus surgery performed?
Endoscopic sinus surgery may be done under local or general anesthesia. Local anesthesia involves numbing the nasal/sinus cavity, but the patient remains awake (or lightly sedated). General anesthesia means that the patient goes to sleep with anesthesia for the surgery. Endoscopic sinus surgery involves the use of a small telescope (nasal endoscope) that is inserted through the nostril to view your nose and sinuses. The goal of the surgery is to identify the narrow channels that connect the sinuses to the nose, enlarge these narrow openings/channels, and improve the drainage from the sinuses into the nose. Most people have four sinuses on each side of their face, for a total of 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, and the frontal sinuses are in your forehead. It is possible that you may not have all of these sinuses due to differences from person to person, or they may have already been opened by previous surgery. Sinusitis may affect some or all of your sinuses. Your symptoms, examination in the physician’s office, and CT scan will determine which sinuses need to be opened. 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 of the nose, may require surgery as well. Additional information about surgery of the nasal septum and turbinates is provided in other sections of this website.
Additionally, there is technology that utilizes balloons to widen the sinus opening. These tools may be used during sinus surgery as described above and can sometimes, for the right patient and sinus disease, be performed in the office.
What is the recovery after endoscopic sinus surgery?
Some nasal packing may be used during your surgery, although in general, this is less common than it was in the past. Your individual surgeon will determine whether nasal packing will be used. The recovery period will vary depending on the surgery performed and the individual patient. Many people do not have much pain after sinus surgery, but every patient is different. Depending on the extent of your surgery, you may be prescribed stronger pain medicine. Generally, postoperative discomfort, congestion, and drainage should improve after the first few days, with mild symptoms sometimes lingering several weeks after the surgery. Because sinus surgery is just one step in treating your sinus disease, your surgeon may also place you on medications that can include saline rinses, nasal steroid sprays, and possibly antibiotics.
will endosocopic sinus surgery improve my symptoms?
The majority of patients who have endoscopic sinus surgery do very well, with significant improvement in their symptoms.
What is “Sinuplasty” (a.k.a Balloon Sinuplasty or balloon dilation)?
"Sinuplasty" refers to a procedure, or specifically a surgical device. This device is similar to balloon angioplasty, which expands the blood vessels in someone’s heart to relieve blockage. In balloon sinuplasty, balloons are placed into the opening of a patient’s sinuses. Expanding the balloon in the narrowed sinus openings allows the openings to become wider. Sinuplasty may also be used along with traditional endoscopic sinus surgery as well.
Like all medical treatments, the information in the popular media may not reflect reality. Although useful, balloon sinuplasty is not for everyone. In many cases standard endoscopic sinus surgery or medical therapy may be the best treatment. However, in some people balloon sinuplasty may be the best option, and may decrease recovery time. Only with a thorough evaluation, along with a CT scan, can your surgeon decide what is the best treatment for your sinuses.
What are the potential complications of endoscopic sinus surgery?
Complications of sinus surgery are rare but include bleeding, damage to the eye or vision, anesthesia complications, and intracranial complications (brain injury, brain fluid leak, infection of the brain). However, it is important to realize that the sinuses are located next to the orbits (eye sockets) and directly beneath the bottom of the brain. Failure to treat chronic rhinosinusitis itself may lead to severe problems, such as infection of the eye or brain. If you are uncomfortable with the risks of sinus surgery, it is important that you discuss this with your surgeon.
See Complications of Nasal & Sinus Surgery.
What are the alternatives to endoscopic sinus surgery?
Continuing medical therapy alone and avoiding surgery is always an alternative. Medical therapy is chiefly antibiotics and/or steroids along with other medications. As with any surgery, you should feel more than comfortable seeking a second opinion from another surgeon.
What is endoscopic skull base surgery?
Over the course of the last ten to fifteen years, abnormalities that involve the areas of the bone at the bottom of the brain and brain itself that are next to the nose and sinuses have been removed via the nostril, without facial incisions. Using cameras and video equipment similar to those used for sinus surgery, these tumors can be removed without facial incisions. Because this technique may be significantly less painful, requires less traction on the brain and necessitates a shorter hospital stay, it is an attractive option for some patients and tumors. However, it must be emphasized that this technique is not for all patients or tumors.
©American Rhinologic Society