Endoscopic Sinus Surgery

What Is Endoscopic Sinus Surgery?

Endoscopic sinus surgery – also called endoscopy or sinoscopy – is a procedure used to remove blockages in the sinuses (the spaces filled with air in some of the bones of the skull). These blockages cause sinusitis, a condition in which the sinuses swell and become clogged, causing pain and impaired breathing.

A thin, lighted instrument called an endoscope is inserted into the nose, and the doctor looks inside through an eyepiece. Much like a telescope with a wide-angle camera lens, the endoscope beams light into different parts of the nose and sinuses, allowing the doctor to see what is causing blockages. Surgical instruments can then be used along with the endoscope to remove the blockages and improve breathing.

This surgery does not involve cutting through the skin, as it is performed entirely through the nostrils. Therefore, most people can go home the same day.

Endoscopic sinus surgery is a relatively new procedure designed to increase the amount of air flowing through the sinuses and allow mucus to drain properly out of the nose. The procedure can:

• Relieve nasal blockages
• Relieve facial pain
• Improve breathing
• Improve the sense of smell and taste

Endoscopic sinus surgery is an effective procedure to correct:

• Sinusitis
• Deviated septum, in which the partition separating the left and right sides of the nose is crooked
• Polyps, a noncancerous water-filled swelling
• Tumors, a swelling caused by an uncontrolled growth of cells

However, it seems to be less effective for those with post-nasal drip or allergies that are caused by airborne particles which cannot be avoided, such as dust and ragweed.

What Conditions Are Treated By Endoscopic Sinus Surgery?

Endoscopic sinus surgery is used to treat:

• Sinusitis
• Deviated septum
• Polyps
• Tumors

Sinusitis

Sinusitis is a common condition that usually is easy to treat with medication. It feels much like a head cold, with a blocked, stuffy, or runny nose.

Sinusitis is actually a swelling of the inner lining of the sinuses. This swelling causes the openings of the nose to be blocked so that the mucus inside can no longer drain out. When the mucus cannot drain, the pressure of the blocked fluid creates pain in the face and impairs breathing.

For most people, sinusitis is a temporary condition that goes away with simple treatment. If the symptoms continue for a significant period of time without responding to medication, or if the symptoms are especially severe, surgery may bring about permanent relief.

However, surgery for sinusitis is considered a last resort and will not be recommended unless all other courses of treatment have been exhausted over a period of time with little or no results.

Sinusitis can be the result of:

• A cold that lingers
• A bacterial or viral infection
• Swelling due to allergies
• Having small sinus openings

Deviated Septum

The partition separating the left and right sides of the nose, called the septum, is sometimes crooked. This crooked condition is called a deviated septum. Some people are born with this abnormality, but sometimes it is the result of an injury.

Very few people have a perfectly straight septum, but endoscopic sinus surgery is only recommended for those whose septum is crooked enough to cause significant sinus blockage. The surgery can then straighten the septum and improve breathing.

Polyps

A polyp, also called a cyst, is a benign (noncancerous) water-filled swelling about the size of a grape, which develops in the sinuses and causes blockage. They most frequently occur in people who have asthma.

Polyps can sometimes be reduced in size with medication. However, endoscopic sinus surgery has proven to be an excellent method with which to remove polyps and restore normal breathing.

Tumors

A tumor is a swelling caused by an uncontrolled growth of cells that creates new tissue. It is not water-filled like a polyp.

A tumor can be noncancerous or cancerous. Tumors in the sinuses are quite uncommon but can sometimes be removed with endoscopic sinus surgery. However, more extensive surgery is often necessary.

About The Sinuses

The sinuses are spaces filled with air in some of the bones of the skull. Air passes in and out of these spaces, and mucus drains through them and out of the nose. They also reduce the weight of the skull and give our voices a nicer sound.

There are four main pairs of sinus openings, sometimes called sinus cavities, in the face:

• Maxillary – in the cheekbones
• Ethmoid – between the eye sockets
• Frontal – in the forehead and above the eyebrows
• Sphenoid – deep in the head at the back of the nose

Each of these pairs of sinus openings has a channel that leads to the nose. These channels are quite narrow, and when the lining of the channels becomes swollen, blockage results. This lining is called the mucous membrane. This same mucous membrane forms the inner lining of the nose.

The mucous membrane in the nose and sinuses is our personal air conditioner. It warms, moistens, and cleans the air. The mucous membrane creates a clear, wet, slightly sticky mucus that gathers any dust, smoke, bacteria, or virus particles that may have been in the air. Tiny hairs along the membrane called cilia act as tiny oars, moving the mucus along much like a conveyor belt through the sinuses and out the nose.

When the mucus containing the unwanted particles reaches the nose and throat, the body prompts us to swallow, spit, sneeze, or cough it out of the body. When a cold or allergy prevents the cilia from moving the mucus through, the nose becomes blocked.

The mucous membrane is also one of the body’s front-line defense systems. It releases chemicals that help to destroy bacteria and viruses before they can attack.

If a virus, bacteria, allergen or other irritant is strong enough to prevent the mucous membrane and cilia from doing their job, blockages can occur in any of the pairs of sinus openings.

Endoscopic sinus surgery can correct chronic or severe blockages in one or more of the maxillary, ethmoid, frontal, or sphenoid sinuses.

What Causes Sinusitis?

The potential causes of sinusitis include:

• Virus
• Bacteria
• Fungus
• Allergies
• Asthma
• Poor air quality
• Extremes of temperature and humidity
• Dehydration
• Excessive nose blowing
• Foreign objects placed in the nose
• Stress
• Diseased teeth
• Hormonal imbalances
• Medication side effects
• Low immune system
• Deviated septum
• Small sinus openings
• Polyps
• Tumors

Most cases of sinusitis can be easily treated by a family doctor. However, in those cases where the sufferer has chronic sinusitis or repeated attacks of acute sinusitis that have not responded to medication, endoscopic sinus surgery may be the answer. This is especially true in the case of nasal obstructions such as polyps.

There are two types of sinusitis:

• Acute sinusitis means that the symptoms of the condition are temporary, usually lasting no more than 30 days. However, the symptoms of acute sinusitis are more severe and painful than the symptoms of chronic sinusitis.
• Chronic sinusitis means that the symptoms of sinusitis occur frequently or for long periods of time. The symptoms are usually more annoying than painful. However, those with chronic sinusitis are more likely to have recurring attacks of acute sinusitis, which can be quite painful.

What Are The Symptoms Of Sinusitis?

Symptoms of sinusitis vary from person to person. The most common symptoms are:

• Stuffy or runny nose
• Clear, thin discharge from the nose (as in chronic sinusitis), or thick yellow or green discharge from the nose, sometimes tinged with blood (as in acute sinusitis)
• Sneezing and/or coughing
• Pain over the bridge of the nose
• Headache that is worse in the morning, when bending forward, or when riding an elevator
• Post-nasal drip from the nose into the throat
• Frequent throat clearing
• Itchy eyes and/or nose
• Impaired sense of smell and/or taste
• Bad breath
• Fever and chills
• Pain in the roof of the mouth or teeth
• Face and eye pain

Less common symptoms, which may or may not be accompanied by a stuffy nose, are:

• Earache, feeling of fullness in the ear, swelling, and tenderness behind the ear, and/or ear popping due to mucus in the eustachian tube of the ear
• Sore throat and hoarse voice caused by infected post-nasal drip
• Swelling of the eye area due to spread of infection from the sinuses to the eye
• Severe headache with vomiting, a very rare symptom, indicates the possibility of meningitis or the spread of infection into the brain.

How Does A Doctor Determine If Sinus Surgery Is Necessary?

The first thing a doctor will do is take a detailed medical history and make note of all symptoms, as well as how long the symptoms have been present. The doctor will need to know any medications being taken, as well as any other conditions such as high blood pressure, eye diseases or bleeding disorders.

• If there is another course of treatment besides surgery that has not yet been tried, the doctor may prescribe new medications.
• If surgery appears to be the best course of action, a CT scan, which is a special type of x-ray, is usually taken so that the doctor can see all of the sinuses prior to using the endoscope. The CT scan serves as a kind of road map for the endoscopic examination.
• Before the endoscopic examination, a nasal spray is used to shrink and anesthetize sinus tissues. The doctor will then insert the endoscope into the nostrils to determine what is causing the sinusitis symptoms, such as thick mucus, swelling, small openings, deviated septum, or polyps.
• The doctor will only perform surgery if the examination shows problems that can be surgically corrected.

In very rare cases, the doctor will determine from medical history and examination that surgery will not correct the problem. In this case, sinusitis symptoms are caused by a separate condition. Those with cystic fibrosis or diseases that cause immune deficiency, such as HIV (human immunodeficiency virus) and AIDS are especially prone to sinusitis.

Preparing For Endoscopic Sinus Surgery

Prior to endoscopic sinus surgery, your doctor may recommend that you do the following:

• Discontinue taking any pain relievers that contain aspirin for at least two weeks prior to surgery, as aspirin thins the blood and promotes bleeding.
• Make an appointment for lab tests two days before surgery (depending upon the doctor’s request).
• Discontinue taking any other medications the day of surgery.
• Do not drink or eat anything after midnight the night before surgery.

What Happens During The Procedure?

The surgery itself lasts 60 to 90 minutes, after which the patient spends an hour or two in a recovery room.

After the doctor has determined the nature of the problem and where it is located, a surgical plan will be made. A simple clearing of the intersection between the two sides of the nose is often all that is needed to relieve symptoms. In this case, a local anesthetic, where the patient remains awake during the procedure, is enough. Some crunching sounds may be heard and a sensation of tightness may be felt during the surgery, but there is no pain.

If there are several blockages deeper in the sinuses or polyps to be removed, a general anesthetic, where the patient is fully asleep, is recommended. The doctor typically begins by clearing the ethmoid sinuses, followed by the sphenoid sinuses, the frontal sinuses, and finally the maxillary sinuses, if necessary.

The doctor will clear any blockages, create larger openings where needed, correct a deviated septum if necessary, and remove any growths such as polyps.

What Happens After Surgery?

• Someone will need to drive the patient home, since both local and general anesthesia can cause drowsiness and disorientation for a short period of time after surgery.
• The nose is usually covered with a gauze dressing that will need to be changed whenever it becomes dirty or wet.
• A packing is placed in the nose after surgery, which requires breathing through the mouth for a short time during the healing process. The packing usually has to be worn for only a few days, and the doctor will advise when it can be removed. It may have a bad odor, however, or cause bad breath.
• Nose blowing should be avoided entirely for at least a week after surgery.
• Sleep on at least two pillows to keep the head elevated.
• It is not uncommon to experience discomfort in the nose and face for a short time after surgery. Mild headaches are also normal.
• Do not take pain relievers containing aspirin without consulting a doctor. Aspirin can promote bleeding and cause problems after surgery.
• Keep the nose as free from dry crusting as possible. A saline spray may be used six to eight times per day to keep the nose moist. Sometimes, the doctor will want to take care of cleaning the area in the office two to three times a week. Generally, however, the patient can make a nasal rinse from 1/4 teaspoon salt, 1/4 teaspoon baking soda, and eight ounces of warm water. A bulb syringe can then be used to squirt the solution into the nostrils whenever necessary.
• Keep activities to a minimum for a couple of weeks, as too much activity can increase the chances of bleeding.
• Do not lift heavy objects, swim, scuba dive, or fly for a few weeks following surgery.
• Avoid caffeine, alcoholic beverages, spicy foods, and antihistamine medications, which can cause drying of the sinus passages.
• Do not use decongestant nasal sprays unless prescribed by a doctor, as these sprays can become addictive after a few days of continuous use.
• Avoid eating dairy products, which can promote excess mucus production.
• Avoid anything that causes allergic reactions.
• Do not smoke, and avoid secondhand smoke.
• Drink plenty of fluids, especially water.
• Use a humidifier, if necessary, to moisten dry air.
• Finish all prescribed antibiotic medication.
• Within a week after surgery, the doctor will set an appointment to check the progress of healing.

What Is The Recovery Period?

Breathing usually returns to normal within 30 to 60 days after surgery. This, of course, is a gradual process and varies from person to person.

It is recommended that individuals stay home from work or school for about a week, to rest and allow the body to heal as fast as possible.

Sometimes, the doctor will prescribe medications after surgery such as steroids or antibiotics, especially if polyps have been removed.

What Are The Most Common Complications of Endoscopic Sinus Surgery?

It is important to note that no surgery is successful in 100% of cases. All surgeries have the potential for complications. With endoscopic sinus surgery, as with most surgeries, serious complications are uncommon. Most complications are not serious and are easily treated with antibiotics or other simple measures.

Any complications from endoscopic sinus surgery are the same as with any type of sinus surgery. While complications are infrequent with all sinus surgeries, there are fewer incidents with endoscopic sinus surgery than the more invasive traditional surgeries.

The most common serious complication, which occurs in approximately 2% of cases, is leakage of the body’s spinal fluid. This is usually discovered during the surgery itself and repaired at that time so that no adverse effects will occur.

The worst and most rare complication is blindness, which is caused by damage to the optic nerve in the eye.

How Does Endoscopic Sinus Surgery Differ From Traditional Surgeries?

There are other types of surgeries that can correct blockages in the nose and sinuses, but endoscopic sinus surgery is becoming the procedure of choice for more and more doctors.

Compared to other more traditional methods, endoscopic sinus surgery:

• Is less painful
• Leaves no visible scars
• Causes less bleeding
• Creates less discomfort after surgery
• Requires less packing in the nose after surgery
• Has a faster recovery period
• Has a higher success rate

When sinus surgery was first performed, surgeons would have to reach the sinuses by entering through the cheek area. This often caused scarring and possible disfigurement. In another traditional procedure, surgeons enter the sinus through the upper jaw.

In the past, it was thought that the damaged sinus tissues could never function normally again and had to be removed. Now, it is believed that as long as enough room is created for air to properly pass through the nose, the sinuses can once again do their job. Therefore, the objective of endoscopic sinus surgery is to do as little as necessary to restore the normal function of the sinuses.

Preventing Future Sinus Problems

It is important to prevent sinusitis symptoms from returning so that the regained sinus health can be preserved.

In the case of allergy attacks, it is important to avoid allergens if at all possible, staying away from any foods, fabrics, smoke, or animals that cause symptoms. If the culprit is in the air, allergy shots or medications may have to be taken regularly to prevent a recurrence of chronic sinusitis or acute sinusitis attacks that could again create sinus blockages.

At the onset of a cold or allergy symptoms:

• Increase your water intake.
• Keep the nostrils moist with salt-water nasal rinses, humidifiers or steam, and saline nasal sprays.
• Avoid excessive forceful nose blowing.
• Discontinue eating dairy products until symptoms subside.
• Consult a doctor immediately if a fever or thick yellow or green mucus are present.

Endoscopic Sinus Surgery: Frequently Asked Questions

Here are some frequently asked questions related to endoscopic sinus surgery.

Q: How do I know if I’m a candidate for endoscopic sinus surgery?

A: If you have chronic sinusitis or frequent attacks of acute sinusitis that have not improved after trying various medications over time, you may be a candidate for endoscopic sinus surgery. Any sinus surgery is considered a last resort, as less expensive and less traumatic treatments are always preferable. However, only a doctor can advise you the best course of treatment after a thorough review of your symptoms and a complete examination.

Q: Can any doctor perform endoscopic sinus surgery?

A: No, only a doctor specializing in sinus disorders, such as an otolaryngologist, can perform sinus surgeries. Since endoscopic sinus surgery is a fairly new and very delicate procedure, it is important to choose a doctor with considerable experience. You might also wish to get the opinion of a second doctor before consenting to any type of sinus surgery.

Q: Can endoscopic sinus surgery be performed on children?

A: Endoscopic sinus surgery is a difficult procedure to perform on children because their sinuses are small and not fully developed. When the sinuses have fully developed, sinusitis symptoms sometimes stop on their own. Therefore, unless there is a nasal obstruction such as a polyp, most doctors will prefer to treat a child with medication.

Q: I had traditional sinus surgery a few years ago, but I still have sinusitis symptoms. Can I have endoscopic sinus surgery?

A: Yes. If your doctor recommends it, it is safe for you to have endoscopic sinus surgery even if you’ve had a different type of sinus surgery in the past.

Q: My sense of taste is not as good as it used to be. Does this mean I need endoscopic sinus surgery?

A: Probably not. A reduced sense of taste has many potential causes, most of which are not sinusitis. However, if you have chronic sinusitis accompanied by an impaired sense of smell, your taste problem may be caused by sinusitis and may improved by endoscopic sinus surgery. It is important to be evaluated by a doctor to determine the true cause of the reduced sense of taste.

Endoscopic Sinus Surgery: Putting It All Together

Here is a summary of the important facts and information related to endoscopic sinus surgery.

• Endoscopic sinus surgery is an outpatient procedure used to remove sinus blockages that cause sinusitis.

• An endoscope is a thin, lighted instrument, much like a telescope with a wide-angle camera lens, which is inserted into the nostrils. The doctor can examine the sinuses by looking through an eyepiece at the opposite end of the endoscope. Surgical instruments can then be used next to the endoscope to remove blockages or growths, such as polyps.

• Endoscopic sinus surgery is an effective procedure for correcting sinusitis, deviated septum, polyps, and sometimes tumors.

• To determine if surgery is recommended, a doctor will take a detailed medical history and list of symptoms, noting how long the symptoms have been present. A CT scan is usually taken next to obtain an overview of the sinuses prior to the use of the endoscope.

• Surgery will be performed only if all other courses of treatment have failed or if symptoms are especially severe.

• Endoscopic sinus surgery lasts 60 to 90 minutes, after which the patient spends an hour or two in a recovery room. As long as the patient has someone else available to drive, he or she can usually go home the same day.

• Full recovery from endoscopic sinus surgery generally takes 30 to 60 days. It is recommended that the person not return to work or school for about a week after surgery.

• Endoscopic sinus surgery has become popular among doctors because it leaves no scars and causes less pain and discomfort for the patient than traditional sinus surgeries.

Endoscopic Sinus Surgery: Glossary

Here are definitions of medical terms related to endoscopic sinus surgery.

Allergen: Any substance that causes an allergic reaction because the immune system recognizes it as “foreign” or “dangerous”

Antibiotic: A drug that kills a bacteria or virus

Antihistamine: A drug that dries excess mucus and blocks allergic reactions

Asthma: A disorder of the lungs that causes wheezing, coughing, and excess

mucus production

Bacteria: A one-celled microorganism that can cause infection

Benign: Not cancerous

Cilia: The tiny hairs along the mucous membrane that move mucus through the sinuses and out the nose

CT Scan: A special x-ray, usually of the head, that provides an overview of the body structures

Cystic Fibrosis: An inherited disease that causes the glands to produce thick mucus

Decongestant: A drug, often in nasal spray form, which shrinks blood vessels and reduces swelling

Dehydration: Too much loss of water from the body tissues

Deviated Septum: A crooked condition of the partition separating the left and right sides of the nose

Endoscope: A thin, lighted instrument, much like a telescope, that is inserted into the nostrils for viewing of the nose and sinuses through an eyepiece

Endoscopy: Endoscopic sinus surgery or examination of the sinuses with an endoscope

Ethmoid Sinuses: The pair of sinus cavities located between the eye sockets

Eustachian Tube: A tube in the inner ear that connects with the nose and throat

Frontal Sinuses: The pair of sinus cavities located in the forehead and above the eyebrows

Fungus: A parasitic plant or mold that can be microscopic and thus, ingested or inhaled

General Anesthetic: A drug that causes the patient to sleep during surgery, so that no pain is experienced during the procedure

Hay Fever: An acute allergic reaction when the seasons change to trees, grass, weeds and pollens

Humidifier: A device that adds moisture to the air

Local Anesthetic: A drug that numbs only the area where surgery will be performed, allowing the patient to stay awake during the procedure

Maxillary Sinuses: The pair of sinus cavities located in the cheekbones

Meningitis : An infection or inflammation of the membranes of the brain and spinal cord

Mucous Membrane: The lining of the nose and sinuses. There are also mucous membranes in other parts of the body

Mucus: The fluid made by the lining of the nose and sinuses, which carries dust and other particles out of the nose

Otolaryngologist: A doctor specializing in disorders of the ears, nose, and throat

Polyp: A noncancerous water-filled swelling

Rhinitis: Swelling of the mucous membrane in the nose, causing a runny nose

Rhinosinusitis: Swelling of the mucous membrane in both the nose and sinuses, usually just called sinusitis

Saline Nasal Spray: A spray containing a mild salt solution that cleans the nasal passages

Septum: The partition separating the left and right sides of the nose

Sinoscopy: Endoscopic sinus surgery or examination of the sinuses with an endoscope

Sinuses: The spaces between the bones in the face where air passes and mucus drains

Sinusitis: A condition of the sinuses that causes swelling and blockage in the nose, resulting in impaired breathing

Sphenoid Sinuses: The pair of sinus cavities located deep in the head at the back of the nose

Steroid: A hormone-like drug

Tumor: A swelling caused by an uncontrolled growth of cells, which can be noncancerous or cancerous

Virus: A tiny organism that feeds on the cells of animals and can cause infection

Endoscopic Sinus Surgery: Additional Sources Of Information

Here are some reliable sources that can provide more information on endoscopic sinus surgery.

National Institute of Allergy and Infectious Disease

http://www.niaid.nih.gov

This organization conducts sinusitis research, and the website contains information about new treatments.

Medline Plus

http://www.nlm.nih.gov/medlineplus/sinusitis.html

This website, maintained by the U.S. National Library of Medicine, contains information about sinusitis and its treatments.

The American Rhinologic Society St. Louis University Department of Otolaryngology

http://www.american-rhinologic.org

The American Rhinologic Society is the only professional organization that deals specifically with sinus surgery, both conventional and endoscopic. Their website features general information on sinus surgery as well as many consumer publications.

Southern California Nasal and Sinus Care Center

http://www.toffelcenter.com

The technique of endoscopic sinus surgery is explained on this website.