G. Aaron Rogers, MD FACS
I have a strong interest in sinus surgery and advanced sinonasal procedures. However performing these procedures should be taken with great caution as the sinuses are basically surrounded by very important anatomical structures, such as the orbits, the brain, the tear ducts, the nerves of olfaction (smell), and several other large named arteries (several, read below) and nerves serving important functions. In the United States, endoscopic sinus surgery (FESS) is very commonly performed. The frequent performance of this surgery allows surgeons the benefit of getting lots of experience (“practice”) but also allows us to see lots of complications from FESS. Unfortunately the financial motivation of performing sinus surgery leads some surgeons to overprescribe or overperform surgery, leading not only to complications but leading to complications that are many times unnecessary (reference this report about how 2/3rds of sinus surgery cranial injuries occur where there was no sinus infection to begin with).
Here I will describe some of my favorite tips to avoid pitfalls and surgical misadventure. This includes some systems-based practices to avoid recommending inappropriate operations to begin with.
Begin with appropriate medical therapy course.
Some duration of medical therapy for sinusitis is nearly always warranted for sinus infections before surgery is entertained. Most sinus infections will in fact clear with medications, and many in fact will clear without any special treatment whatsoever. The biggest single thing that the sinus surgeon can do to reduce the occurrence of operative complications is to reduce the occurrence of unnecessary surgery! In my office, the typical chronic sinusitis patient is not be offered surgical treatments without at least 3-4 weeks of a broad spectrum antibiotic (and attempt at culture with culture-directed antibiotic if possible), regular compliance and failure of nasal steroids, trial of nasal saline, and evaluation of allergy symptoms or immunodeficiency when appropriate. Meeting these “criteria” for sinus surgery typically means that sinus symptoms have been occurring for several months before surgery is appropriate. [Note in cases of aggressive or complicated sinus infections this timeline is advanced as needed, ie there are times we may even operate same day if the situation requires.]
Culture-directed antibiotic therapy is based upon a sample of drainage taken from the sinus ostium (opening) usually only visible with a nasal endoscope. By identifying the exact bacterium in the lab causing the infection we are able to prescribe the most appropriate antibiotic (and likewise know when oral antibiotics may not work).
While most patients do well with a good course of appropriate antibiotics, we also do need to make real exceptions in the case of the elderly, those with complex medical histories and those with gastrointestinal problems. Antibiotics themselves may wreak significant harm on some individuals. If a quick minimally invasive treatment may be appropriate for complex patient, it may be ultimately better to forego a long and perhaps risky medical therapy course.
Recent evaluation of allergies is also appropriate for anyone considering sinus surgery. Many of the symptoms of sinusitis may in fact be caused more by allergies than by the actual infection. While many patients with allergies still need sinus surgery, knowing the full story on nasal allergies is ultimately better for treatment and for appropriate expectations after surgery.
Appropriate pre-operative sinus imaging.
Good high resolution imaging of the sinuses and related bony structures is important not only for the best diagnosis possible, but even moreso for surgical planning. Sinus imaging used to be done by standard CT or spiral CT, but now a more practical method is “cone beam” technology that is more readily available, allows better spatial resolution of the bony sinus walls, and carries about 1/9th the standard radiation dose of a CT scan.
We use imaging extensively to assess severity of chronic sinusitis, identify risk factors in recurrent acute sinusitis, and at times monitor our medical therapy. With good imaging we can very accurately grade the extent of infection to better quantify exactly which of the sinus regions are affected and therefore which may benefit from surgery. Finally these scans are often used in surgery with image guided surgery systems to add an extra layer of safety during sinus procedures.
Another reason to get good imaging done prior to finalizing surgical plans to be sure that “sinus infections” or “sinus inflammation” are the underlying problem to begin with. Sinus pressure headaches may be caused by all sorts of things – not just infections. Many times migraines, temporomandibular joint disorder (TMJ or TMDD), trigeminal neuralgia or tension headache can greatly confuse the picture. At times these kinds of headaches also respond to some of the sinus and allergy medication. Almost half the patients I see who have been treated for “chronic sinus headache” have no sign of a sinus infection or sinus blockage – they have a neurological or muscular form of headache. And every week I am seeing someone new in second-opinion consultation who continues to have the same headaches (maybe even worse) after maximal sinus surgery elsewhere – probably because sinus surgery wasn’t appropriate to begin with.
A Plan that Makes Sense.
The surgeon and patient should discuss exactly which areas are to be addressed with surgery and the special risks of operating on those areas. The surgeon should of course have a good reason (from endoscopic or CT scan findings) to be operating in each of the sinus areas. ENT’s divvy the sinuses up into five areas on each side, for a total of ten “sinuses”. The surgical plan should basically answer “how many and to what degree is each sinus being opened?” For example a simple infected cyst in the cheek sinus (maxillary) should not require all ten sinuses to be opened (and opening all ten sinuses in this case subjects the patient to slightly more risk and substantially more recovery than needed). Most ENT’s agree that there is limited reason to extend the sinus operation to sinuses that are not affected/infected/swollen on CT scan – that is, healthy sinuses usually do not usually need an operation. There are always exceptions of course, but even in the case of an exception there should still be a good reason.