Surgery:

Surgery can unblock the sinuses when drug therapy is not effective or if there are other complications, such as structural abnormalities or fungal sinusitis.

Insertion of a Drainage Tube

The simplest surgical approach is the insertion of a drainage tube into the sinuses followed by an infusion of sterile water to flush them out.

Functional Endoscopic Sinus Surgery

Functional endoscopic sinus surgery (FESS) is the standard procedure for most patients requiring surgical management of chronic sinusitis or polyposis. The procedure allows correction of obstructions, including any polyp and ventilation and drainage to aid healing.

Candidates for the Procedure.

• In general, patients should have tried and failed extensive medical therapy. This usually includes several prolonged courses of broad-spectrum antibiotics, nasal corticosteroids, nasal saline irrigation, allergy testing and immunotherapy where appropriate, and sinus drainage where appropriate.
• Patients with nasal polyps or sinus polyps who have failed intranasal and possibly oral corticosteroids generally require surgery.
• Patients with congenital anatomic abnormalities.
• Patients with evidence of bone involvement.
• Patients with HIV who have chronic or recurrent sinusitis.

Surgery may not be as effective for patients with the fungal infections or severe chronic sinusitis, although endoscopy is proving to be beneficial even for these conditions with the use of more powerful instruments.

Procedure. The surgery generally proceeds as follows:

• Adults need only a local anesthetic for the procedure, though a general anesthetic is needed for children.
• Before the procedure, a computed tomography (CT) scan is taken for use by the surgeon in planning the procedure and as a guide to the sinuses during surgery.
• A flexible tube, a miniature camera, and a fiberoptic light source are inserted through a single small opening.
• Instruments are then used to remove diseased bone or tissue and clear obstructions. For instance, shavers are used to gently remove soft tissue. Bone cutters are sometimes employed to open the floor of the frontal sinus and restore drainage (called the modified Lothrop procedure). Lasers may be used to remove bone, coagulate the passageways, or clear obstructions.

Complications. Serious complications of FESS are very rare, but the following have been reported in a few cases:

• Cerebrospinal fluid leak is the most common major complication, but it occurs in only 0.2% of cases and is usually easily repaired during surgery.
• Other very rare complications include meningitis, hemorrhage, infection, or vision loss.
• Patients can develop infections afterward that are very difficult to treat. Interesting studies are reporting good-to-excellent results in these patients by spraying antibiotics into the nasal passages using a nebulizer.

Postsurgical Care. Postsurgical care involves the following:

• The patient will experience a dull ache around the nose and sinus cavity that can be treated with pain medication.
• Following surgery, the patient should flush the sinuses twice daily with a saline or alkaline solution.
• Antibiotics may be prescribed for several weeks until postnasal drip has stopped, and corticosteroid sprays and antihistamines may be needed.

Success Rates. It may take several months for the mucus membranes to completely recover, but 85 - 90% of patients have good to excellent relief of their symptoms after surgery. Children may need a second procedure 2 - 3 weeks after the first surgery to remove crusty matter.

Balloon Sinuplasty

A new type of surgical procedure threads a small balloon through the sinus passages. As the balloon is gently opened, the sinus passages expand, allowing drainage to occur. Some doctors think that this procedure is only appropriate for select patients with sinusitis disease in the maxillary (behind cheek bones), frontal (behind the sides of the forehead), and sphenoid (behind the eyes) sinus regions. It may not work for patients with disease in the ethmoid (between the eyes) sinuses, even though sinusitis commonly occurs in this location. More long-term studies are needed.

Invasive Conventional Surgery

Endoscopy is now used in most cases of chronic sinusitis, but in severe cases, invasive surgery using conventional scalpel techniques to remove infected areas may be required. This may be the case with acute ethmoid sinusitis in which pus breaks through the sinus and threatens the eye, with very severe frontal sinusitis, with invasive fungal sinusitis, or when cancer is present in the sinuses.