What is Functional Endoscopic Sinus Surgery?
One way functional endoscopic sinus surgery differs from conventional sinus surgery is that an endoscope is used in the nose to view the nasal cavity and sinuses. This generally eliminates the need for an external incision. The endoscope allows for better visualization of diseased or problem areas. This endoscopic view, along with detailed x-ray studies, may reveal a problem that was not evident before.
Another difference is that functional endoscopic sinus surgery focuses on treating the underlying cause of the problem. The ethmoid areas are usually opened, which allows for visualization of the maxillary, frontal, and sphenoid sinuses. The sinuses can then be viewed directly, and diseased or obstructive tissue removed if necessary. There is often less removal of normal tissue, and the sinus surgery can frequently be performed on an outpatient basis.
When is Endoscopic Sinus Surgery Indicated?
Endoscopic sinus surgery is generally intended for people with chronic sinus problems who do not respond to medical therapy. The diagnosis of chronic sinusitis must be based on an assessment by your doctor, as other problems can cause symptoms similar to those found with sinus disease. The majority of people with sinusitis do not require surgery. Their sinus symptoms can usually be successfully treated medically, including antibiotic therapy and other medications, treatment of allergy, and environmental control. The type of medical therapy used is based on your doctor’s assessment of the cause.
However, in some people surgical intervention is required as a sinus treatment. This may be because an infected or inflamed area does not clear with antibiotic therapy or other medications, the symptoms keep returning when antibiotics are stopped, or for other reasons. You should discuss the need for sinus surgery with your doctor.
How Am I Evaluated/Scheduled for Endoscopic Sinus Surgery?
The decision to have sinus surgery will be based on your history and physical exam. At the initial consultation, it is important to bring records from your doctor including your history and sinus treatment up to this time. If a previous CT scan or MRI is available, it should also be brought to your first visit. A CT scan is required to accurately assess the areas involved. If not done prior to your visit, one will need to be done at a later time.
Medical therapy may be initiated, based on your evaluation, to see how you respond to maximal medical treatment before deciding on a surgical procedure. If it is felt that you would benefit from endoscopic sinus surgery, your consent will be obtained and a date will be arranged for the procedure.
How Do I Prepare for Sinus Surgery?
Prior to sinus surgery, you will need to have some blood work and possibly some other studies performed. To be current, blood work should be done within one month of surgery. Other studies include an EKG and chest x-ray, which are ordered if your age or medical history indicates a need. This testing can be done here at the Cleveland Clinic, or locally. If done locally, results need to be forwarded to us at least two weeks prior to the scheduled surgery date so they can be reviewed.
Typically, you will have a visit to be re-examined prior to surgery. For convenience, pre-operative studies can be arranged at Cleveland Clinic. If you have a CT scan from outside this institution, bring it with you to this visit. Surgery will not be performed without the CT scan.
In some cases, starting oral steroids (or increasing the dose if you are already on them) and/or antibiotic therapy is done in the pre-surgical period. Take these medications as directed by us. If you have a significant increase in your sinus infection in the week(s) prior to surgery, notify us. Your sinus surgery may need to be postponed.
Do not take aspirin or salicylate containing analgesics for at least ten days prior to surgery. Aspirin, even in small quantities, can significantly increase bleeding during surgery and post-operatively.
Do not take non-steroidal anti-inflammatory drugs (Ibuprofen, Advil, Motrin, Aleve) for at least five days prior to sinus surgery. These drugs will also increase bleeding, although the effects on the blood are shorter.
Do not smoke for at least three weeks prior to surgery. Not only does smoking worsen sinus symptoms, smoking in the weeks before or after surgery will result in excessive scarring, and may result in failure of the operation.
Do not eat or drink anything beginning at midnight the night before sinus surgery. If you are taking medications, ask during your pre-surgical evaluation if these can be taken on the morning of surgery.
You should obtain some Afrin nasal spray from your pharmacy, and spray into the nose one to two hours prior to the operation.
What Will Happen During Sinus Surgery?
The surgery is typically not uncomfortable and should not be an unpleasant experience. The operation can be performed under general or local anesthesia, with an anesthesiologist providing monitored sedation. Your physician will discuss the advantages/disadvantages of each type, and together you will decide which is right for you. Although there are potentially serious risks from surgery in this area, the incidence of these risks is very low (see Risks of Endoscopic Sinus Surgery).
If you choose local anesthesia, you will be given medication to make you sleepy and relaxed, and will be provided with some headphone music. You may bring your own CD/cassette if you like. You will usually hear some crunching sounds as bone is removed which may sound loud to you. You may also feel some mucus or blood in the back of your throat that you should swallow. You will be able to talk to us during the surgery, so let us know if anything bothers you. Should you experience significant discomfort during the procedure, we will provide monitored sedation.
In some cases it may be necessary to repair the nasal septum at the time of sinus surgery. If this is required, additional risks associated with septal repair are possible (see Risks of Endoscopic Sinus Surgery).
What Are the Risks of Endoscopic Sinus Surgery?
Although the risk of bleeding appears to be reduced with this type of sinus surgery, on occasion significant bleeding may require termination of the procedure and the placement of nasal packing. Bleeding following surgery could require placement of nasal packing and hospital admission. A blood transfusion is very rarely necessary.
In the rare instance that a blood transfusion is necessary, there is a risk of adverse reaction or the transfer of infection.
Cerebral Spinal Fluid (CSF) Leak
All operations on the ethmoid sinus carry a rare chance of creating a leak of CSF (the fluid that surrounds the brain). The risk of CSF leak is generally considered higher when ethmoid surgery is done through the nose instead of by external incision. However, because the endoscope used allows for improved visualization, the risk of this complication is potentially reduced. Should this rare complication occur, it creates a potential pathway for infection, which could result in meningitis (inflammation of the brain). A CSF leak would extend your hospitalization and may require further surgery for repair.
Although extremely rare, there are occasional reports of visual loss after sinus surgery. Usually, the loss of vision only involves one side and the chance for recovery is not good. Temporary or prolonged double vision has also been reported after sinus treatment.
Because endoscopic sinus surgery is typically performed under local anesthesia, adverse reactions are uncommon. If general anesthesia is required, you would be subject to the occasional but possibly serious risks involved. Adverse reactions to general anesthesia may be further discussed with the anesthesiologist.
Nasal Septum Reconstruction Risks
If nasal septal reconstruction is done, you could experience numbness of the front teeth, bleeding and infection in the nasal septum, or the creation of a septal perforation. A septal perforation is a hole through the septum, which may cause difficulty breathing through the nose. Since the cartilage in the septum has a “memory,” it may shift post-operatively and result in a renewed deviation. There is also a small risk of a change in shape of the nose.
Decreased Sense of Smell
Permanent loss or decrease in the sense of smell can occur following surgery. However, in a number of patients, it is already decreased prior to surgery, and typically improves with surgical intervention.
Tearing of the eye can occasionally result from sinus surgery or sinus inflammation and may be persistent. You may experience numbness or discomfort in the upper front teeth for a period of time. Swelling, bruising, or temporary numbness of the lip may occur, as well as swelling or bruising around the eye. Subtle changes in the sound of your voice are common.
What Can I Expect Following Surgery?
Some bloody postnasal discharge may occur for approximately two weeks after this procedure. This is normal and slowly improves. You should not blow your nose for at least four to seven days following sinus surgery. As normal sinus drainage becomes reestablished, you may blow out some thick bloody mucus. This is also normal.
Follow-up visits are usually arranged at approximately one and six days after surgery to clean crusts from the nose. Further follow-up visits are arranged at weekly intervals until the area is healed (four or more weeks). During follow-up visits, any persistent inflammation or scar tissue will be removed under local anesthesia. Although chances of complications from these manipulations are rare, the potential risks are the same as with the surgery itself. Consent to the surgery also includes consent to post-operative care.
Careful post-operative care is essential to the success of this surgery. You will be provided with a brochure addressing post-operative care instructions. It is very important that you follow these instructions, as well as any additional instructions given by us, to promote healing and decrease the chance of complications.
Will Endoscopic Sinus Surgery Cure My Sinus Problems?
As with all sinus surgery, it is possible that the disease may not be cured by the operation, or that disease may recur at a later time. If this should happen, subsequent surgical therapy may be required. It should be realized that some medical therapy is usually continued after surgery, especially if allergy or polyps play a role in the sinus disease. This is necessary to prevent recurrence of disease.
Overall, the majority of patients has had significant improvement with the combination of surgery and continued medical management. We will certainly work with you to attain this goal.