Endoscopic Sinus Surgery

 Endoscopic sinus surgery is performed for those people who have chronic or acute sinusitis that persists for greater than six weeks after maximum medical therapy. Prior to surgical treatment, maximum medical therapy usually consists of antibiotics given at either 10-14 day intervals, with follow up visits at 10-14 day intervals and continuous antibiotic therapy without interruption as long as clinical evidence of sinus disease exists. Usually accompanied with the last course of antibiotic therapy, prior to consideration of surgical treatment oral steroids are used. Other medications usually prescribed are nasal steroid spray and decongestant mucus thinner medication. If the medical treatment does not resolve clinical picture of chronic or an acute sinusitis during a six week interval of maximum medical therapy CT scan is appropriate to be done at that time. A CT scan is a series of pictures that which will usually provide the patient and the physician with complete information as to whether or not there still exists sinus disease.
 
 If there is still sinus disease despite this treatment surgical options should be entertained. Surgical treatment is then directed at the sinuses that appear to have chronic disease still present. The procedure is done through the nose not usually requiring any incisions on the outside of the face, except on rare occasions. This is done with endoscopes which provide good visualization and with micro instruments. There is power instrumentation which is being used also, which affords removal of tissue i.e. polyps which is tissue containing edema, that usually protrudes from the sinuses from chronic inflammation. This inflammation can be due to allergies chronic bacterial sinus infections, viral infections, or commonly associated when there is benign or malignant tumor associated to the nose or sinuses. This procedure is commonly done under general anesthesia, but can be done under either local, with sedation, or under general anesthesia.
     The risks of surgery are the same as the risks of chronic and acute sinusitis, and these include changes in vision infections spread to the eye cavity, periorbital abscess and blindness. Intercranial complications can be cerebral spinal fluid leak (CFS leak), meningitis, brain abscess. These usually occur in less than1/10th of 1% of the time. The procedure is done as an out patient most commonly, and patients who remain in the hospital overnight for observation, usually are those who have other problems such as asthma, which can be associated with sinus disease, and/or obstructive sleep apnea, or due to excessive amounts of pain, nausea or vomiting. Generally the patient goes home the same day. They are instructed to sleep with their head up for the next five days. The slapstick splints that are usually placed during this procedure are removed at five days. This procedure can be done in conjunction with septoplasty, turbinectomy or turbunoplasty, to help improve breathing if nasal obstruction exists in addition to the sinus disease. Follow up usually occurs at 4-5 days post-operatively,1 week postoperatively,2 weeks post-operatively,3 weeks post-operatively, then on a monthly basis for a total of three months post-operatively.
 
 Things that can be helpful is the use of a Rhino therm machine after removal of silastic splints, and this is usually done at my office at least 2-3 days a week for the first two weeks, at least once a week for the next month and then as needed. Some patients come in and have this done on a daily basis once the splints are removed, and that is at their discretion. A Rhino therm machine is used to project small particles of moist saline nebulization into the nose to help loosen mucus and crusting so that it’s easily removed, and decreases the amount of trauma during the post operative visits.
 
 One of the main things to be concerned about with regards to sinus disease, is that sinuses is that sinuses are not removed during this procedure. The opening is usually enlarged, trying to preserve the natural mucosa in the sinuses as much as possible, so we provide adequate drainage and relieve any obstruction that is present. Post nasal drainage and drainage from the sinuses is improved by this procedure and drainage should be expected. It is our hopes that drainage is not noted post operatively. Sinus disease is most commonly associated with stasis of mucus or fluid within the sinuses, creating an environment conductive to bacterial growth. Patients are given antibiotic therapy decongestant mucus thinner, salt water nose spray and pain medication, in the post operative period.
     They are instructed to follow up with their physician at any time if they should develop increasing pain, fever, swelling around the eye or edema of the white portion of the eye. Also if there is any change in vision. Patients are encouraged not to blow their nose during the post operative period because sometimes small defects can be found in the lateral wall of the ethmoid sinus and on blowing the nose ,air can go from the nose to the orbital cavity causing a bulging of the tissue of the eye. This is usually not a problem within two weeks after the procedure. Most common sinuses that are addressed in endoscopic sinus surgery are the ethmoid sinuses and the maxillary sinus opening. Additional procedures need to be done when there is a distinct sinus disease noted in the sphenoid sinus, primarily just to open the sinus opening more widely to afford adequate drainage. When the frontal sinus is a problem, most of the time by relieving the ethmoid sinus disease, the frontal sinus will drain appropriately and no surgery is indicated for the frontal sinus. 90% of the people do not require significant amounts of additional sinus surgery. Those people who develop or continue to have persistent frontal sinus disease, surgeries to address the frontal sinus may be necessary.
 
 The surgeries most common to address frontal sinus disease is a frontal orifice exploration, and this is an edoscopic procedure to identify the opening of the frontal sinus and to make sure that there is no diseased tissue blocking the frontal sinus. The frontal sinus opening can usually be intubated with a suction or a frontal sinus probe, to provide adequate irrigation and removal of any mucus or pus within the sinus. Additional procedures associated with a with a frontal sinus orifice exploration is a frontal sinus trephine. This is a small hole made in the wall of the frontal sinus to provide adequate visualization through an endoscopic and/or irrigation and removal of tissue, and to make sure that a frontal sinus stint can be placed and does go into appropriate position.
 
 There are additional frontal sinus procedures such as a Lathrop procedure, which is an endoscopic procedure using power instruments, including a drill to open the frontal sinus opening widely. If frontal sinus disease persists despite these procedures, a consideration for frontal sinus obliteration can be done. Frontal sinus obliteration is done for chronic frontal sinus disease that cannot be relieved by other procedures previously noted above. This is done by either Gull wing brow incisions or the time done by a bi-coronal incision, with opening of the anterior wall of the frontal sinus, and removal of all frontal sinus mucosa.  The drainage site for the frontal sinus is then packed with muscle and the frontal sinus itself is then packed with fat. This is also necessary to have done if there is frontal sinus disease., or a frontal sinus fracture under the appropriate indications. These can be with frontal sinus disease or fracture that goes through the anterior wall or the posterior wall.
 
 Usually when the posterior defect is noted and is significant a frontal sinus obliteration is performed, but is usually done by removal of the frontal sinus, posterior wall and allowing the brain cavity to come forward filling and obliterating what was previously the frontal sinus opening or space. In all of these instances ,the frontal sinus opening that drains into the ethmoid sinus and nose is closed by packing of this area muscle. Patients who have had sinus surgery in the past are encouraged to follow up with their surgeon at any time that they detect any sinus disease what so ever. Immediate treatment is very helpful in precluding the need for additional sinus procedures.