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Sinus Surgery: 2008 Update

Issue: June 2008

By: Winston Vaughan, MD

Sinus surgery is one of the most common procedures that ENTs currently perform. Many aspects of sinus surgery have dramatically improved compared to what many patients and doctors considered the standard experience. These include changes that lead to mostly endoscopic surgeries (not external), done as an outpatient, with much faster recovery and no or very limited packing. Also dedicated sinus centers with fellowship-trained sinus surgeons often focus on more difficult cases.

Functional endoscopic sinus surgery (FESS) is a minimally-invasive surgery. With FESS, there no visible incisions and recovery is often 1 to 2 weeks. Nasal packing is rarely used and, if so, new dissolvable ones are available that can be washed out by the patient.

The most commonly used instruments are small cutting forceps. Endoscopic powered “shavers,” also called microdebriders, may be used for polyp removal and to take down portions of the ethmoid sinuses. These, however, are very powerful tools that may remove too much tissue or cause other complications. Careful technique is crucial. There are computer navigation systems (also referred to as CT or MRI image-guidance systems) that are used to reconfirm the surgeon’s endoscopic view of tissues. This gives a CT-guided estimate of the surgeon’s instrument location. Such systems are indicated in a case with more complex anatomy or altered by previous treatments or disease.

Minor complications may include bleeding, pain/discomfort, congestion, and infection. Scar tissue formation is a significant risk that over time can lead to surgical failure due to ostial stenosis. This is reduced by aggressive cleaning of the nasal cavities after surgery (debridement). Major risks may include CSF leak or orbital injury. If a CSF leak occurs, it is generally identified during the procedure and repaired endoscopically with tissue from the nose and tissue sealers. Orbital injuries can be significant and avoidance is paramount. To reduce overall complication rates, careful plans by highly experienced surgeons and nursing teams are essential. Success rates will vary depending on the location, extent and type of sinus disease seen before surgery, surgical skill and post surgical healing. Disease that is limited has higher success rate. Hence, a patient with chronic sinusitis in just one maxillary sinus will do much better than a patient more sinuses affected with polyps, triggered by allergic fungal sinusitis and associated with asthma.

Other surgical procedures may be done with FESS. These include sleep apnea surgeries, septoplasty, rhinoplasty and facial rejuvenation procedures. FESS techniques can also be used in more complex cases, often with eye and brain surgeons, such as orbital decompression for thyroid-related eye disease or endoscopic approaches to the skull base and pituitary.

A new surgical device that patients may ask for is called Balloon Sinuplasty™. These devices, like angioplasty, are catheter-based tools used to dilate the sinus openings. A small balloon catheter is passed over a guidewire. The balloon is inflated so that it gradually dilates the sinus osita. The sinus can then be drained and the interior of the sinus may be examined.

Balloon Sinuplasty™ involves little to no tissue removal. It is only used to open the frontal, maxillary and sphenoid sinuses. These devices were introduced about 5 years ago. More data is starting to emerge on long-term outcomes and they are favorable in the carefully selected patient.

Most sinus problems can be medically managed without surgery. However, when surgery is needed, FESS has been shown to have excellent outcomes and very high patient satisfaction ratings.

Winston Vaughan, M.D. is fellowship trained in rhinology and advanced sinus surgery. Dr. Vaughan is based in Palo Alto. Visit www.calsinus.com for more information.

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