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Endoscopic Sinus Surgery: What you need to know

Introduction:
Chronic sinusitis is an illness characterized by prolonged infection and inflammation of the lining of the nose and the sinuses. Patients with chronic sinusitis experience a variety of symptoms, including facial pressure, nasal congestion, discolored nasal discharge and “post-nasal drip”. A diagnosis of sinusitis should be made only after careful evaluation by your doctor. Most patients with sinus infections can be successfully treated with medications. For the majority of patients with sinusitis, surgery is not required.
For a small percentage of patients, however, medications alone are not adequate to completely clear their infections. In these patients, infections recur soon after completing even long courses of medications. Such patients who fail to respond to medications will often require surgery. After reviewing your medical history and x-ray results, your ear, nose and throat specialist can help you determine if you are a surgical candidate.

1. What is Endoscopic Sinus Surgery?
   Endoscopic sinus surgery is a procedure designed to open the natural drainage pathways of the sinuses to restore their function and health. In chronic sinusitis, the sinuses are unable to drain adequately due to inflammation of the drainage pathways. As a result, nasal secretion become trapped in the sinuses and become chronically infected.
   The goal of surgery is to carefully remove the tiny, delicate bone and mucous membranes that block the drainage pathways of the sinuses. The term “Endoscopic” refers to the use of small fiber optic telescopes that allow all of the surgery to be performed through the nostrils, without the need for any skin incisions. Endoscopic sinus surgery may be performed under either local or general anesthesia. Due to the length of the surgery it is best done under general anesthesia to ensure your comfort. The operation takes on average from 1 ½ to 3 hours, depending on how extensive the disease is. The surgery is generally performed on an outpatient basis.
   

2. What can I expect before, during and after surgery?
   Before Surgery: In preparation, for your surgery, we may prescribe a preoperative regimen of medications for you in order to optimize the condition of your sinuses for surgery. The medications may include antibiotics and/or oral steroids. If we deem any preoperative medications necessary, please be sure to start the medications on the appropriate day and adhere closely to the prescription.
   In addition, you should avoid taking aspirin and all aspirin-related products for at least fourteen days prior to surgery. Aspirin, ibuprofen (Motrin/ Advil), naproxen (Aleve), and related products can thin the blood and create excessive bleeding both during and in the postoperative period. Tylenol is safe when taken as directed, and may be taken anytime up to the day of surgery.
   If you smoke, it is critical that you stop smoking for at least three weeks prior to surgery (and at least four weeks after surgery). Smoking during this critical window can seriously interfere with the success of the operations, resulting in excessive scarring and failure of the operation. Your physician can help direct you to resources to assist you with smoking cessation.
   
   Finally, it is important that you inform your primary care physician that you are planning to have sinus surgery. Your primary care physician can be of great assistance in helping to make sure that you are medically cleared for surgery and that you have all the necessary testing performed. Please make sure that your surgery can proceed as planned. We will make every effort to keep your primary care physician informed regarding your medical status both before and after your surgery.
   
   During Surgery: Most cases are done under general anesthesia. If you have health conditions, which prevent you from having a general anesthetic, it is possible to have the surgery under a local anesthetic. With a general anesthetic, you will be asleep for the entire procedure. When your surgery is completed, you will spend one to two hours in the recovery room, followed by an additional period of recovery in the Short Stay Unit. Most patients feel well enough to go home the day of surgery. Usually, the nasal packing is removed before you leave the hospital. Occasionally however, patients need to go home with small nasal packs on both sides of the nose. This will be removed in the office the day after surgery. You will be given pain medications, saline nasal spray, and sometimes antibiotics. Some patients may require a one night stay in the hospital if they need additional recovery time of if they have other medical problems that require special attention.
   
   After Surgery: The first postoperative visit is made one week after surgery, unless your packing needs to be removed. In that case, you will return to the office on the day after surgery and your packing will be removed and some blood may be suctioned out of the nose if needed. Otherwise, at the first postoperative appointment, your sinuses will be cleaned out with suction. This may be uncomfortable and you should take a pain pill 1-2 hours before the appointment. It is best to have someone drive you. Using your nasal spray often will help decrease the discomfort.
   Your visits will then be scheduled on a weekly basis until proper healing is assured. In general, this requires approximately 3-4 weekly visits. Thereafter, your visits will be spaced several weeks apart, depending on how well your sinuses are healing. It is essential that you return for all scheduled follow-up appointments, as careful postoperative care is critical to the success of your surgery. After 3-4 months, most patients’ sinuses have nearly healed, and visits for maintenance care are then made as needed.

3. What are the risks of surgery?
   As with any surgical procedure, Endoscopic sinus surgery has associated risks. Although the chance of a complication occurring is very small, it is important that you understand the potential complications and ask your surgeon about any concerns that you may have.
   
   • Bleeding: Most sinus surgery involves some degree of blood loss, which is generally well tolerated by the patient. However, on occasion, significant bleeding may require termination of the procedure. In addition, postoperative bleeding sometimes may occur after the packing has been removed, and new nasal packing may need to be replaced until control of bleeding is assured. Blood transfusion is rarely necessary and is given only if the patient’s health would otherwise be compromised.
   
   • Recurrence of disease: Although Endoscopic sinus surgery provides significant symptomatic benefits for the vast majority of patients; surgery is not a cure for sinusitis. Therefore, you can expect to continue with your sinus medications even after successful sinus surgery. In general your requirements for such medications should be lessened. In some instances, additional “touch-up” surgery may be necessary to optimize your surgical outcome.
   
   • Spinal fluid leak: Because the sinuses are located in close proximity to the brain, there is a rare chance of creating a leak of spinal fluid (the fluid surrounding the brain and spinal cord) or injuring the brain. Should the rare complications of a spinal fluid leak occur, it may create a potential pathway for infection, which could result in meningitis (an infection of the spinal fluid). If a spinal leak were to occur, it might require surgical closure and that would extend your hospitalization.
   
   • Visual problems: There have been isolated reports of visual loss after sinus surgery. The potential for recovery in such cases is not good. Fortunately such a complication is extremely rare. Double vision has also been reported following sinus surgery. Persistent tearing of the eye can result from surgery, but this problem usually resolves on its own.
   
   • Other risks: Other uncommon risks of surgery include permanent alteration of sense of smell or taste; persistence and/or worsening sinus symptoms and facial pain; swelling of bruising of the area around the eye. Temporary loss of sense of smell or taste is common and usually resolves after 1 month.
   Some patients have a deviation of the nasal septum that needs to be corrected at the time of surgery through a short procedure called septoplasty. If you require septoplasty, there are additional risks associated with this procedure. The primary risks are bleeding of infection in the area of the septum; numbness of the front teeth; the development of a hole through the septum (septal perforation); recurrence of septal deviation. There is a very small risk that such occurrences could alter the external appearance of the nose.

4. What will my activity restrictions during the postoperative recovery period?
   For the first week following surgery you should not blow your nose. A saline spray may be used several times per day to relieve nasal irritation. In addition, you should not perform exercise or any other exertional activity for at least two weeks following surgery. This includes no bending, lifting (more than about 10 lbs.), or straining. Your surgeon will be able to advise you when it is safe to being exercising again. You should plan on taking one to two weeks off from work to recover from surgery. Finally, we ask you not to travel out of the area for at least 2 weeks after surgery. Airplane travel will be very painful for 2-3 weeks after surgery. Please check with me before scheduling any flights.

5. When will I start feeling better?
   It is very important to understand that you may actually feel worse for the first 2-3 weeks after surgery. The surgery itself causes inflammation. You will be VERY FATIGUED and may have several days of headache pain. You will not begin to feel better for 2-3 weeks and will not appreciate the full benefit of your surgery for 1-2 months so please be patient.
   
   Conclusion:
   We are committed to providing you with the highest level of care in a comfortable and caring environment. We want you to start feeling better as soon as possible. We also want you to have a complete understanding about your sinus condition and about my recommendations for treatment. You need to feel comfortable with all aspects of the treatment plan, including surgery. Please feel free to ask questions about any aspect of your care, and we will be happy to make sure that all of your questions have been answered.