Information About Sinus Disease

The sinuses (paranasal sinuses) are four-paired cavities within the bones of the face. They amplify our voices and protect our faces from impact. Their other functions are a guess, but allowing each of us to talk and sound different from one another is likely their key function.

The openings into our nostrils are lined with a delicate membrane. This membrane serves the function of warming and humidifying all of the air that we breathe. In addition, the special sense of smell is provided by nerves high in the roof of the nose. The sinuses drain into the nose, and are affected by the same diseases that affect the function of the nose.

The four-paired sinuses are:

• Frontal -- in the forehead, above the eyes
• Ethmoid -- between the eyes
• Maxillary -- in the facial bones below the eyes
• Sphenoid -- behind the ethmoids, behind and between the eyes

Anything that causes the nasal membranes to swell and block breathing may affect the ability of the sinuses to drain properly. An inflammation of the nose is called
"rhinitis", and literally means an "itis" (inflammation) of the "rhino" (nose). Causes of rhinitis are the common viral cold, bacterial infections, allergies, or common irritants such as smoke. Variations in temperature, humidity and barometric pressure (the most important) may also affect the health of the nasal membranes.

Anytime the nasal membranes swell for more the a few days, the sinuses may drain poorly and fill up with mucus. If this blockage continues, this mucus may start to serve as a "culture tube" for the bacteria that live in the nose. One statement here deserves clarification; namely, every time the mucus changes color, we don't need to be on antibiotics. If we can restore the drainage mechanism the color will go away on it's own. When we are unable to restore this drainage, antibiotics may be required in conjunction with treatment to restore the normal function of the nose.

Sinusitis means the sinuses have an inflammation and are filled with fluid or swollen, poorly cleansing membranes. This invariably follows an acute case of rhinitis, or as a flare-up in a patient with a chronic stuffy nose when another irritant, infection, or allergen is present.
 
The treatment of sinusitis tries to restore the nose to a moist, open state. Treatment of sinusitis without addressing nasal disease will fail as sure as "the sun is coming up tomorrow". Therefore, we must treat the rhinitis to help cure sinusitis.

Rhinitis is basically a medical disease therefore, surgery will not cure the stuffy, weeping nose of allergies, tobacco abuse or sensitivity to changes in barometric pressure. We all have felt a "sinus" attack before the weather changes or after being exposed to noxious fumes.

Four treatments exist for chronic or recurrent rhinosinusitis:

1. Avoidance -- move to "Minnesota" or quit smoking.
   
2. Allergy -- diagnosis and management with avoidance, medications, or allergy shots. If you suspect allergies are playing a major role, please let us know.
   
3. Medications -- that is antihistamines, decongestants, nose sprays, mucus-loosening drugs, or antibiotics.
   
4. Surgery

Most patients should be treated with intensive medical care, including medications to promote drainage, decrease inflammation and fight infections, prior to considering surgery. The main goal of surgery is to make patients responsive to medicines. This can been realized the great majority of the time. However, treatment of chronic rhinitis, or stuffy nose may continue well beyond surgery.

In patients who have failed on medications, we will often perform a special examination of the nasal passages to assess anatomic problems that may be leading to "nasal and sinus failure" -- nasal endoscopy. This means a magnified view of the nose and sinus passages with lighted, magnifying lenses. This is performed in the exam chair with a local numbing nose spray.

A Special X-Ray called a CT (computerized tomogram) will also be ordered. This allows us to see great detail of the face and sinuses. This is generally performed in the office.

If the endoscopy and CT scans show disease that has not responded to medications, then surgery may be recommended.

Nasal and sinus surgery is performed to open nasal and sinus passages so that they can drain themselves of infection. This operation is performed through the nose using the same instruments, called endoscopes, that we use in the office. All incisions are made inside the nose, and no external signs of the operation are generally visible.

The operation is accomplished using an anesthetic that sedates the patient to the point of sleep, or a general anesthetic in which the patient is rendered unconscious. Please discuss the type of anesthetic preferred, if you elect to proceed with surgery.
 
The sinus operations are named after the sinuses that are drained. All include "ectomy" or "otomy" meaning to open or partially remove:

1. Maxillary antrostomy = enlarging the natural opening into the maxillary sinus
   
2. Ethmoidectomy = enlarging the sinus cavities between the eyes. Key to other sinus drainage
   
3. Frontal sinusotomy = enlarging the opening above the ethmoids to drain the frontal sinuses
   
4. Sphenoid sinusotomy = creating a larger drainage hole into the sphenoid sinus

Often a nasal septoplasty is performed to straighten a crooked, or deviated partition between the two nasal cavities. The lining membranes of the nose may be "reduced" by turbinate reductions or partial turbinectomies. These two procedures are performed at the same time as sinus surgery if needed, and deal with breathing through the nose. The surgery generally requires 1- 2 hours for completion, and is performed as an outpatient procedure in ~95% of cases.

Complications other than stuffy nose and excessive drainage are uncommon. Excessive bleeding usually can be managed without surgical treatment, but about 1 in 100 patients will require nasal packing to be reinserted into the nose in the first two weeks after surgery. We place a sponge pack into the nose in about 5 % of patients. Most surgery is performed without packing. The risk of needing blood transfusion is rare.

The eye structures are located just outside the ethmoid sinus. Damage to the eye muscles can lead to double vision. Damage to the optic nerve can lead to blindness in extremely rare cases (estimated at 1 in 10,000 cases). Excessive tearing occurs for a few weeks in about 1 in 100 patients, but may be permanent or require further surgery in rare cases.

The frontal lobes of the brain are located immediately above the ethmoid and sphenoid sinus. Opening the bone above these sinuses may lead to brain fluid leaking into the nose (cerebrospinal fluid leak), or severe, even life?threatening bleeding or infection. The risk of these complications is estimated at 1 in 10,000 cases.
Most patients will want to be off work for two or three days after surgery, but some can return the day after if no packing is required and no heavy lifting is required by the job. Most should plan to limit themselves to light activity for two weeks, that is no physical activity that is considered "exercise".
 
Sinus surgery is now very much an accepted part of the management of troublesome disease. Expect an improvement in nasal breathing and a decrease in a need for antibiotics. The surgery is extremely effective for the stuffy nose in about 90% of cases. As usual, results may vary by patient, and no guarantees of success can be given. There are just too many variables to guarantee this surgery.

Please read this over before seeing the doctor if you are considering surgery. This will allow our surgeons to spend more time answering your questions, not you answering ours. Thousands of patients have benefited by our care in the past, and hope lies in the future for those who address the causes of their nasal and sinus disease. We hope this information is helpful to you, please feel free to offer suggestions as to how we may serve you better.