Surgery for Rhinosinusitis

Hopkins C, Surda P, Walker A, Wolf A, Speth M, Jacques T, et al. EPOS 4 patients. Rhinology. 2021 Suppl. 30: 1-57.

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The role of surgery in treating chronic sinus disease

The majority of people suffering from chronic sinus problems are successfully treated medically and do not require surgery. However, in some patients the underlying inflammation does not resolve with sprays, drops or tablets. In these cases, patients find that despite using these medicines their symptoms keep coming back or do not improve at all. In such cases, surgery can be considered.

 

Different types of surgery

Endoscopic Sinus Surgery (ESS) is a term that surgeons use to describe the most common technique for operating on sinus disease. It was previously called “functional endoscopic sinus surgery” or FESS because it aimed to restore the normal physiology of the sinuses to produce mucus and drain into the main nasal cavity together with ventilation of the system to reduce inflammation. The word “endoscopic” means using a slim surgical telescope that enables all of the operations to be performed via the nostrils without any cuts or scars to the outside of your nose. On rare occasions, if your sinus disease is extensive or complex then an external cut may be considered - but your sur- geon would discuss this with you before the operation.

The term “sinus surgery” is used as an umbrella term to reflect that there is a variety of technical procedures that can be chosen to tailor the procedure to your sinus disease:

  • Polypectomy: removal of nasal polyps

  • ‘Mini ESS’: approach involving simple ventilation of the maxillary and anterior ethmoid sinuses (usually in mild disease)

  • ‘Full House ESS’: opening of all sinuses including maxillary sinus, ethmoidal sinuses, sphenoid sinus and frontal sinus

  • Extended endoscopic surgery: usually performed as a revision surgery in cases of severe resistant chronic rhinosinusitis

  • Balloon sinuplasty: gentle stretching of a sinus opening using a small balloon to enhance the natural drainage path of the large nasal sinuses suitable in only selected cases

ESS is usually performed when you are asleep (general anaesthesia). In some cases, it can be done under local anaesthetic which allows surgery to be performed while you are awake.

How does surgery work?

The goal of surgery is to open any sinuses which are inflamed and to create an environment that reduces the risk of that inflammation returning after surgery.

 

The goals of surgery, therefore include:

  • Allowing washes and medicated sprays to get where they need to go

  • Achieve adequate ventilation

  • Improvement of sinus drainage

  • Restoration of normal nasal functioning

This is done by removal of polyps (if present), small amounts of bone and inflamed tissue that are blocking the sinuses.

Key steps in endoscopic sinus surgery

The ostiomeatal complex, or the common sinus drainage unit, shown in the image below, is the focus of almost all endoscopic surgical technique, which largely aims to enlarge the sinus ostia to improve drainage of secretions and access to topical therapy.

 

Partitions that divide the sinuses into a series of smaller cells are carefully removed creating larger open cavities and widened ‘ostia’ or sinus openings.

Surgery in Rhinosinusitis, Endoscopic sinus surgery

Risks of surgery

In an ideal world, we would be able to offer a treatment for sinus disease that was both remarkably effective and also completely safe. Unfortunately, virtually all medical treatments whether tablets, sprays, or operations will be associated with some risks. Each time a new treatment is started, your doctor will discuss with you the benefits, risks, and alternatives (including what would happen if you had no treatment at all).

All surgical procedures have consequences like a small amount of post-operative bleeding, and it is quite common to suffer regular but short-lasting nosebleeds after ESS. However, if the bleeding is severe or prolonged, help should be urgently sought. Infection is reasonably common after ESS and if you suffer an infection then you should discuss with a doctor whether antibiotics are required.

 

Minor complications are self-limiting and include damage to the eye socket that presents as a ‘black eye’ or swelling of the skin around the eye caused by infection, or a watery eye. The contents of the eye socket may be damaged resulting in impaired eye movements or loss of vision, but these are exceedingly rare.

 

There is also a very small number of patients who may have an injury to the portion of the skull that shares a party wall with the sinus cavity. This can cause a leak of the fluid that normally surrounds the brain (cerebrospinal fluid or “CSF”). If this would

arise during surgery, the surgeon can repair it with no additional related complications postoperatively.

 

Surgeons are very mindful of the impact that these complications have on their patients and do everything within their power to minimise the potential risks. There are many scientific papers that examine the rate of complications during sinus surgery and report these estimates:

  • Minor bleeding or infection: common

  • Black eye: 1 in 500 patients

  • Severe bleeding, CSF leak: 1-2 in 1000 patients

  • Visual disturbance: less than 1 in 10 000 patients

However, it is important to note that these figures come from large databases and may not be relevant to your surgeon or your sinus disease. Your surgeon will be happy to discuss these risks with you before planning an operation.

 

Outcomes of surgery and risk of recurrence

Overall, you should expect a significant improvement of symptoms that are related to chronic rhinosinusitis such as blocked nose, smell, nasal discharge, and mucus running into the back of your throat (although the change in post-nasal drip is more unpredictable). The successful outcome of the surgery is reported by more than 8 out of 10 patients. In most cases, as CRS is an inflammatory disease and is not cured by surgery, the aim is to create an environment that allows for nasal medications to get access to the sinuses in order to be effective. Therefore, having surgery does not remove the need for nasal treatments and they are likely to be used for the rest of your life. Giving the chronic nature of sinus inflammation, approximately 1 in 10 patients

will require revision surgery within 3 years. Patients with severe asthma or aspirin intolerance are more likely to require revision surgery than other patients.

 

What are packs and how are they used

Depending on the extent of the procedure and surgeon’s preference, you might need what is called nasal packing. This is when your doctor places sponge-like material in the nasal cavity to absorb blood or other fluids right after surgery. It also may be soaked with anti-inflammatory medication that may improve healing after the surgery. Your doctor will inform you if packing dissolve by itself, or if it must be removed.

 

What to expect during recovery

The healing process of the nasal cavities varies from patient to patient and may take just a few days after polypectomy, ‘mini’ ESS and balloon sinuplasty while it usually takes 2 weeks for ‘full house’ ESS. Some patients may have mild nasal pain and headache, especially during the first week after surgery, which can be well controlled using paracetamol/acetaminophen tablets as needed.

Many patients are able to return to normal daily activities after 8-10 days but it may take longer before you feel fully recovered. You should usually plan to take two weeks off from work, sport, and exercise although everyone recovers at different rates.

Some things you will need to remember during the recovery period:

  • Sleep with your head raised, perhaps using an extra pillow, for a while.

  • Avoid blowing your nose for a week or so, except after nasal rinsing.

  • Try to keep your mouth open when you sneeze. This will take some of the pressure off your nasal cavities.

 

Post-operative medications and how to use them

In the postoperative period, nasal saline irrigations are strongly recommended to clean the nose from secretions, blood clots and nasal crusting; they should be repeated at least twice per day. Nasal rinses can be done using a squeeze bottle, neti pot, or syringe, lean forward over the sink, at about a 45-degree angle. The tip of the device should go inside your nose, no further than a finger's width. Keeping your mouth open, squeeze the bulb syringe or bottle, or tilt the pot to pour the water into your nostril. Remember to breathe through your mouth, not your nose. The saltwater will run through your nasal passages and drain out of your other nostril and maybe your mouth. The procedure should be repeated with your other nostril, and, finally, you can blow your nose gently to clear out the remaining solution. They are usually started soon after surgery but your doctor will advise on this.

Nasal corticosteroids, administered in addition to nasal irrigations or as nasal spray, are effective in preventing polyp recurrence for patients affected by chronic rhinosinusitis and should be continued for the long term, based on ENT doctor advice. In very selected cases, your doctor might also prescribe you also an antibiotic treatment to be taken after surgery, however, this is unnecessary in most cases.

At the time of your hospital discharge, your next follow-up appointments will be scheduled. During the outpatient visits, the sinus openings are checked using and in your nostrils. In some cases, debridement (active cleaning) might be necessary to promote the healing process of the nasal cavities by suctioning secretions or blood clots and removing nasal crusting.

 

Role of septoplasty and turbinate surgery at the same time. Some patients may have sinus surgery combined with other nasal procedures such as:

  • Septoplasty: straightening of the cartilage in the middle of your nose

  • Turbinoplasty: improving the airflow by remodelling some of the bone in the nasal passage called the inferior turbinate

 

These procedures are useful especially for those patients complaining of severe nasal blockage non-responsive to medical treatments. If appropriate for your case, the ENT doctor will extensively discuss with you the need for such procedures before surgery.

 

Patient’s experience with endoscopic sinus surgery

Patient 1 reports:

I have experienced multiple episodes of rhinosinusitis with nasal obstruction, facial pain, nasal discharge, and secretions running into the back of my throat. I don’t get any relief with any nasal spray, even after long courses. I decided to trust my ENT doctor who proposed to me a surgical procedure called ESS to solve

 

my problem. The same evening after surgery I was sleeping at home in my bed. I followed the postoperative medical prescriptions meticulously, including many nasal irrigations every day. My surgeon checked my nose with the telescope two times after surgery in the first postoperative month. Now, three months after surgery have passed, and I could not have asked for a better outcome.

 

Video 1 shows the final result obtained three months after ESS, with patency of sinuses openings:

Patient 2 reports:

I was submitted to surgery for nasal polyps. Few days after hospital discharge, I had to go back to the steel mill where I work and I didn’t have much time for medications. One week after surgery, I began to have purulent nasal discharge and a bad smell from my nose. So, I pushed my appointment up to get a medical consultation immediately. The endoscopic evaluation of my nose revealed an infection and the medical doctor performed

a medication to remove crusting and to suction secretions. The doctor did not seem concerned by it but advised me to start antibiotic treatment, so I focused on getting better. Now the problem is solved and I have learned that it is important to always perform prescribed care, especially after surgery.

 

Video 2 shows the nasal infection developed after surgery:

Patient 3 reports:

At the time of referral to tertiary centre, I have had already three surgeries for nasal polyps. Doctor explained that in my case, the chronic rhinosinusitis was complicated by asthma and aspirin intolerance where both appropriate medical therapy and surgery are essential. I was really scared to go ‘under the knife’ once again, especially because my last surgery was just a couple of years ago. At last, I made up my mind. The surgery went well and lasted less than two hours. My nose was packed for 24 hours and the day after surgery I began to breathe again. I’ve then started nasal treatments and I’ve learned that they should be used for the rest of my life: it's not a problem, as long as I can continue to breathe through my nose like now.

 

Video 3 shows the final result obtained six months after extended endoscopic endonasal surgery, with patency of sinuses openings:

Frequently asked questions

When should surgery be considered?

Nasal surgery should be considered when the medical treatment recommended by your ENT specialist has failed to improve your symptoms or to achieve long term control despite ongoing use. It might also be considered if there is evidence of complications, or if you are unable to use medical treatments due to side effects or other conditions.

 

I really do not want to have surgery, are there any risks if I refuse?

If your doctor feels that surgery is the best choice for you, it usually means that you did not respond well to medicines. In the vast majority of cases, postponing or not having surgery would result in ongoing uncontrolled symptoms such as nasal blockage or loss of smell which might get worse over time. Although it is very unlikely to be a risk to your general health, rarely, inflammation may spread from the nose to the brain or your polyps might expand and cause pressure on your eye socket or nasal bones.

 

Do polyps always grow back after surgery?

Giving the chronic nature of sinus inflammation, approximately 1 in 10 patients with nasal polyps will require revision surgery within 3 years, and I in 5 within 5 years. Patients with severe asthma or aspirin intolerance tend to require more operations than other patients, and often do not get as much improvement in their symptoms despite using the same (or even more) medications. It’s paramount to use nasal treatments regularly as prescribed in order to prevent, or at least slowdown, the polyps’ regrowth.

 

Is sinus surgery painful?

No, not really. Some patients may have mild nasal pain and headache, especially during the first week after surgery, which usually is well controlled using paracetamol/acetaminophen tablets as needed. Your doctor may prescribe stronger painkillers but these are often not needed. You will feel quite congested, and this might be helped by using saltwater rinses after surgery.

 

 

Will I have black eyes after surgery?

Very unlikely, but it may happen. If that occurs, bruising will resolve within 10 days and you should not blow the nose during this time.

 

How long do I have to stay in the hospital after my operation? This depends on the extent of surgery but in most cases, ESS is performed as a day-case procedure meaning that you are discharged on the same day.

 

How long is the recovery?

The healing process takes just a few days for polypectomy, ‘mini’ ESS and balloon sinuplasty while it usually takes up to 2 weeks for ‘full house’ ESS. Many patients are able to return to normal daily activities after 8-10 days but it may take longer before you feel fully recovered. You should usually plan to take two weeks off from work, sport, and exercise although everyone recovers at different rates.

 

I am having revision surgery – is it riskier?

Revision surgery is performed in patients who have been already operated, therefore distorted anatomy and scarring may make it more difficult for your surgeon. They will be happy to discuss these risks with you before planning an operation.

 

I’m on aspirin after desensitisation – do I have to stop it for surgery?

Endoscopic sinus surgery is usually performed before starting aspirin desensitization treatment. However, if you are currently on aspirin after desensitization and surgery have been scheduled for you, the aspirin treatment can usually be continued. Your doctor will advise if you need to reduce the dosage and how to do it. There are also some useful guides for aspirin management on the Samter’s Society website (see the section on patient resources).

 

Will surgery solve my problems forever?

Many people can achieve long-term control of their symptoms but will usually require ongoing medical management. However, there is a chance that further surgery may be required in the future. Your surgeon will discuss different ways to reduce the risk of needing further surgery with you.