Sinus Surgery
Mark E. Reiber, MD, FACS, FAAOA
Recurrent infections or chronic nasal blockage may not only be allergy, but from structural problems. You may easily see a deviated septum or large polyp obstructing the nose or endoscopic exam will reveal problems. Finally, a CAT scan can provide a roadmap of all the nasal and sinus structures.
The most common surgical procedures for the nose are:
Septoplasty
Septal cartilage and bone divides the nose into right and left halves. It can become crooked from birth, trauma, other abnormalities, or just simply as “part of life”. A deviated septum causes obstruction, increased susceptibility to nosebleeds, and makes access for sinus surgery more difficult.
Obstruction is generally worse when supine due to venous pooling of blood and swelling. Patients often try topical decongestants for relief but this leads to dependency and rebound congestion.
Septoplasty is an outpatient procedure, done through the nostrils, with no external incisions or bruising. Recovery is about a week; tolerance and satisfaction are high. Complications are rare but include: need for revision, septal perforation, infection, bleeding, and numbness or sensory abnormalities of the face or teeth.
Turbinate Reductions
Turbinates are shelf-like structures extending from the sides of the nose and covering the sinus openings and tear ducts. Each side has an inferior, middle, superior and sometimes supreme turbinates.
The inferior turbinates may be seen just inside the nose and are sometimes mistaken for a nasal mass. They warm and humidify the air in the nose. In allergy, they become large, pale, boggy, and watery. Various methods have been developed to reduce their size.
The middle turbinates cover drainage openings of the sinuses. They are usually preserved during sinus surgery, but may be removed or trimmed. A concha bullosa cell is a naturally enlarged air cell in the center of the middle turbinate that can cause sinus blockage, headaches, and nasal obstruction.
Endoscopic Sinus Surgery
Today, almost all sinus surgery is performed with endoscopes and small instruments through the nose. Newer techniques utilize “shavers” and balloon catheters to remove tissue and dilate openings. The days of gauze packing have disappeared and most cases require only jelly like dissolvable materials. These advancements have made surgery less painful and shortened recovery times.
Surgery is necessary for irreversible chronic infections, structural problems, and a few other situations. The goal of most procedures is to open the sinus’ natural openings to re-establish drainage. After surgery, keeping the openings patent and limiting scarring is critical to long term success.
Maxillary Sinus
These are the large paired sinuses under the eyes. Pain from them is in the mid-face, below the eyes, and in the upper teeth. The sinus lining has small hairs on the surface directing mucus flow towards the top of the sinus and into the nose through a small opening. Surgery enlarges this opening with either a balloon catheter or endoscopic instruments.
Ethmoid Sinus
These are honeycomb-like air cells along the middle wall of the eye. The bone has an egg-shell consistency easily broken and opened. The frontal sinus drains through the front cells and the sphenoid near the rear. Pain resulting from the ethmoid sinus is between the eyes. Balloon catheter techniques are not appropriate for ethmoids.
Frontal Sinus
Frontal sinuses can be massive, small or non-existent. They are paired in the forehead, above the eyes, where pain may be felt. Most headaches in this area are not the result of frontal sinus disease. This is the most inaccessible and difficult sinus for a surgeon. Balloon catheter techniques have shown the most promise, but numerous procedures have been designed to deal with this difficult sinus.Sphenoid Sinus
These paired sinuses lie next to one another in the middle of the rear of the nose. Pain associated with these sinuses is behind the eyes or at the top of the head. Balloon catheter techniques are useful to enlarge their openings or it can be done with traditional techniques.