Most patients suffering with signs and symptoms of sinusitis find relief with medical treatments. Nasal steroids, nasal anti-histamines, saline nasal irrigation, oral anti-histamines, and oral anti-leukotrienes along with a vast supply of over-the-counter (OTC) medications are sufficient for most patients with sinus pressure, pain, congestion, smell disturbances, and headaches.
On occasion antibiotics and oral steroids may also be used to treat patients with recurrent sinus infections. For some patients; however, these medications are insufficient to provide long-term relief, and symptoms persist despite prolonged medical therapy. In instances where the sinus function is impeded as a result of structural blockage, surgery may be recommended as a way to remove the blockage and open the sinuses to restore natural drainage.
Anatomy of the Sinuses
There are 4 chamber-like sinuses on each side of the face. These are named the Maxillary sinuses (below the eyes), Frontal sinuses (above the eyes), Ethmoid sinuses (between the eyes), and Sphenoid sinuses (all the way in the back). The Ethmoid sinuses may be divided into an anterior (front) and posterior (back) group. The sinuses drain through small openings – called “ostia” – into the nasal cavity. Mucous drains down the nasal cavity and into the throat from where it is swallowed into the esophagus and stomach. Each sinus drains into a specified area. The maxillary, anterior ethmoid and frontal sinuses all drain into the “middle meatus”. The posterior ethmoid sinuses drain into the “superior meatus”, and the sphenoid sinuses drain into the “spheno-ethmoidal recess”.
The sinuses are lined by a mucous-producing mucosa. The mucosa produces over one liter of mucous daily, so it is imperative that the drainage pathways remain clear and open. When the sinus lining swells – from allergies, irritants (dust, chemicals), infections – the drainage openings narrow, and mucous production increases leading to a back-up. If the situation persists it can lead to infection (acute rhinosinusitis) or long-term swelling and sinus dysfunction (chronic rhinosinusitis).
In situations where structural blockage is determined to be a significant causative factor of sinus blockage, inflammation, or infection, surgical correction may be recommended. Below please find descriptions of sinus surgery along with answers for associated frequently asked questions.
The Benefits of Sinus Surgery (Functional Endoscopic Sinus Surgery)
Patients who suffer from persistent or recurrent signs and symptoms of sinusitis which have not responded to medical interventions and therapies, and who have a structural component contributing to their sinus blockage may benefit from surgical intervention. Patients typically report significant improvement in their sinus-related symptoms after surgery. This includes decrease in sinus-related facial pressure, congestion, nasal obstruction, rhinorrhea, and headache. Multiple studies support improvement in patient-reported quality of life measures, as well as objective findings on nasal endoscopy and CT scans. Published data demonstrates that even patients with other factors (co-morbidities) which might impact outcomes – asthma, smoking, allergies, prior sinus surgery – experience significant improvement after sinus surgery. In some cases, patients may still need medications (ie-nasal steroid sprays, nasal anti-histamines, saline irrigations, etc) to treat and manage the underlying disease process (sinusitis); however, unlike before surgery the medications are typically more effective since the sinuses will be open and accessible to topical medicines.
Who is a Candidate for a Sinus Surgery?
Your physician will typically look for the least invasive means to help you manage your sinusitis symptoms and decrease the impact of sinus inflammation on your quality of life. In most cases, this will involve a series of medical treatments such as prescribed and over-the-counter oral pills, topical sprays, and irrigations. Ancillary tests – CT scans, allergy testing, etc – may be ordered to identify the root cause of your sinus swelling. In cases where medications do not provide sufficient, sustainable, long-term relief, and where there is felt to be a structural component to the sinus blockage, surgery may be considered. Opening the small sinus ostia is performed as a means to restore natural sinus drainage and to allow the sinus lining to return to its normal, healthy state.
Your Sinus Surgery Consultation
A visit to your ENT doctor or a telemedicine consultation will include a thorough review of your symptoms, as well as a history of any medications and other treatments that you have tried in the past. Your physician will look for medications that you have not tried, or perhaps medications you have tried that may be worth trying again in combination with other treatments. A focused exam – typically including a brief nasal endoscopy – will be performed to assess the status of the nose and sinus anatomy, and to identify any obvious abnormalities that might be contributing to your sinus condition. Prior testing will be reviewed, and further testing may be ordered. Once a complete assessment has been performed, a treatment plan will be developed and reviewed with you. This may include surgery, or perhaps an additional trial of medications to see if success can be achieved without surgery. If you decide with your physician that surgery is an appropriate next step, details about the particular procedures to be performed will be discussed, and any and all questions answered.
What is Functional Endoscopic Sinus Surgery (FESS) and how is it performed?
FESS is surgery designed to open blocked sinuses and restore natural drainage pathways. The past decade has seen significant evolution in the surgery, so that it is now typically performed as a minimally-invasive, outpatient procedure. Small (4mm) endoscopes are placed in a patient’s nostrils to access and visualize the sinuses. These endoscopes are available with a variety of angled lenses to allow maximal visualization of the sinuses. Using specially designed surgical instruments the sinus ostia are identified and enlarged. Obstructing tissue and bone are carefully removed taking care to preserve the sinus lining which will usually return to its natural, healthy state once surgical healing is completed. In many cases, your surgeon will perform your sinus surgery using an Image Guidance Navigation System –a type of specialized GPS system which allows real-time tracking of surgical instrumentation in 3 dimensions. Also, dissolvable sutures are often used to keep the operated structures in place while they heal. Small absorbable spacers may also be placed for this purpose, as well as dissolvable implants which give off medications for several weeks to assist in the healing process.
Why Choose Our Specialists?
- Dr. Daniel G. Becker, Founder and Medical Director of The Penn Medicine Becker ENT & Allergy Center, is a highly trained, board-certified specialist who graduated magna cum laude from Harvard College in 1986.
- Dr. Samuel S. Becker, Director of Rhinology at The Penn Medicine Becker ENT & Allergy Center, is a highly trained, board-certified specialist who graduated from Amherst College in 1991 and attended medical school at the University of California San Francisco.
- Dr. Kenneth Rosenstein is a highly trained, board certified otolaryngologist who attended medical school at Mcgill University, and completed his residency training at the prestigious New York Eye and Ear Infirmary.
- Dr. Naomi Gregory is a highly trained, board certified otolaryngologist who specializes in the diagnosis and treatment of diseases of the ear, nose, and throat. Dr. Gregory completed medical school at the Philadelphia College of Osteopathic Medicine in Philadelphia PA.
- Dr. Michael Lupa, MD is a highly trained, board certified otolaryngologist with additional training in sinus surgery and allergy treatment as well as advanced skull base surgery. He studied Biology at Tufts University and went on to complete medical school at Case Western University School of Medicine in Cleveland, Ohio.
- Dr. Robert Mignone is a highly trained, board-certified otolaryngologist-head and neck surgeon who attended medical school at New York College of Osteopathic Medicine.
- Dr. Aubrey McCullough is a highly trained otolaryngologist, facial plastic and head and neck surgeon who completed medical school at Midwestern University Arizona College of Osteopathic Medicine.
- Dr. Luke Kim is an otolaryngologist who specializes in the diagnosis, medical management, and surgical treatment of diseases of the ear, nose, and throat. Dr. Kim graduated with honors and with distinction from Cornell University and completed his medical studies at the Perelman School of Medicine at the University of Pennsylvania.
In some cases, additional anatomical structures may contribute to a patient’s symptoms and should be addressed in order to maximize outcomes. Septal deviation, enlarged turbinates, enlarged adenoids, concha bullosa are all adjacent structures that may impact a patient’s nose and sinus related health. If surgery on these structures is recommended, it can usually be performed during the same operation. Your surgeon will of course discuss what is most suitable for your particular situation.
Sinus Surgery FAQs
Where your sinus surgery is performed depends on the specifics of your surgery, as well as your general health and medical status. Most sinus surgery in the United States is typically performed at an Ambulatory Surgery Center (ASC). In some cases, sinus procedures are performed in the office setting. In more complex cases, or in patients with health conditions (cardiac disease, pulmonary disease, patients on blood thinners, etc) where it is preferable that they be observed and/or monitored in a hospital setting overnight, surgery may be performed in a standard hospital operating room.
In most cases FESS is performed under general anesthesia with the patient “asleep”. In some circumstances – typically in an office-based setting – surgery may be performed with a patient awake under “local” anesthesia. Details of what is most suitable for your surgery should be discussed with your surgeon.
In past decades, the entire nasal cavity was packed at the end of surgery. Patients describe extreme discomfort with packing. Today, there are few surgeons that still pack the nose; however, it is important to ask your surgeon to be sure. Some surgeons may use pre-fabricated packs left in for a day, or silastic splints left in for a day to a week. In most cases, no packing is used by surgeons at Penn Medicine Becker ENT & Allergy. But it is always best to discuss with your surgeon to confirm.
Sinus surgery for chronic sinusitis is performed in a minimally-invasive fashion with the sinuses accessed with small endoscopes placed in the nostrils. There should be no change to the facial or nasal appearance after surgery. This includes no black eyes or bruises.
Maybe. Sinus surgery involves opening the sinuses and taking steps to keep them open. In some cases, structures may be sutured to ensure that they do not move after surgery, and heal in the “open” position. In most cases, when sutures are used during sinus surgery, they are dissolvable sutures that do not need to be removed.
How painful is sinus surgery?
Most patients describe mild discomfort after sinus surgery. While patients are typically given a low-dose narcotic to use during the first few days after surgery, many report that they do not take the narcotics and that their post-operative pain and discomfort is adequately managed with OTC pain relievers like Tylenol (Acetaminophen).
How long will I need to take off from work after sinus surgery?
This is very patient-dependent, but most patients take off a few days from work. Heavy lifting and vigorous exercise typically should be avoided for 1-2 weeks; however, details should be discussed with your surgeon.
Will I still need to take medicines after sinus surgery?
In some cases, opening the sinus passages alone restores the sinuses to their natural state and patients do well with minimal to no medications. In other cases, patients may still experience sinus swelling and infections; however, with the sinuses open, topical medications can reach the sinus lining and effectively reduce inflammation and treat infection with less medication (especially oral medications) than would have been needed before the sinuses were opened. Medication needs may vary person to person and even season to season, but in general it is hoped that after surgery patients will experience improved management of their sinus symptoms with decreased medication utilization.
When can I eat after surgery?
There are few limitations on eating after sinus surgery. Eating may be impacted in some cases by nausea after anesthesia, but for the most part, patients can eat what and when they feel up to it. Of course, details should be discussed with your surgeon and answers may vary based on your particular medical history, medications, anesthesia, and procedure.