Rhinology and sinus surgery is a subspecialty that manages nasal and sinus problems. Common problems we treat are allergies, nasal obstruction, and sinusitis. Less common conditions, such as tumors of the sinuses or anterior skull base can also be treated with minimally invasive techniques.
The specific services we offer are listed below:
- Allergy treatment
- Endoscopic sinus surgery
- Functional nasal surgery (such as septoplasty)
- Nasal and sinus disorder (sinusitis) treatment
- Skull base surgery
What are the sinuses, and what do they do?
The sinuses are hollow chambers placed within the bones of the face and skull. They are located next to the nasal cavity and are anatomically named the paranasal sinuses. Four sets of sinuses lie on each side of the nasal cavity: frontal, ethmoid, maxillary, and sphenoid sinuses. The frontal sinuses occupy the bone over the eyes in the forehead while the maxillary sinuses are under the eyes in the cheekbones. The ethmoid sinuses are actually a collection of sinuses, like a honeycomb, which lie between the eyes. The sphenoid sinuses are placed behind the nasal cavity and eyes, near the center of the head.
We don’t really know why we have sinuses, which makes it all the more frustrating when we have sinus problems. Many theories have been proposed, all of which may be correct. By creating air-filled chambers within the skull bones, the sinuses may serve to decrease the weight of the head. They also add resonance to the voice; when they are blocked up we sound like we are talking through our noses. In a more practical sense, the sinuses form a sort of "crumple zone" that protects the eyes and brain in case of a severe injury to the face.
We know that we don’t breathe through our sinuses and we don’t use them for our sense of smell either. When we breathe, air goes through the nasal cavity like a hallway with a divider running down the middle. That divider is called the septum, and in some people it can be crooked. When this happens, it’s called a deviated septum, and, if sufficiently crooked, can cause blockage of the airflow.
The sense of smell is actually located far back in the nasal cavity, within the ceiling of the hallway. The nasal cavity hallway has areas like rooms on either side that have very small doorways that connect them to the hallway. These rooms are the sinuses and the doorways can be only a few millimeters (1/16 to 1/8 of an inch) wide. When air passes up and down the hallway, some of the air within the sinus rooms does get exchanged and refreshed. This is why some people feel as though they can’t breathe through their sinuses. They are feeling the lack of air exchange with each breath.
The nasal cavity hallway and sinus rooms have a special type of wallpaper called mucosa that has a number of functions. The mucosa wallpaper secretes mucus that traps particles inhaled into the nose and keeps the wallpaper surface moist. It has proteins within it that form part of the immune system as well. The wallpaper mucosa not only produces this mucus but also transports it from within the sinuses to the opening and into the nasal cavity hallway. This is accomplished by the millions of microscopic hari-like structures on the lining cells of the nose and sinuses, called cilia. The cilia beat in a coordinated fashion to move the secretions and their trapped particles from the sinuses into the nose and from the front of the nose toward the back. In fact, under normal circumstances it takes only eight to ten minutes for the mucus to get from the front to the back.
The mucus goes into the throat where it is swallowed and the trapped particles are destroyed in the stomach. Despite producing a large amount of mucus that is transported constantly, we typically aren’t aware of this process unless the nose and/or sinuses become inflamed, as in sinusitis. Dryness in the nose can also interfere with the secretion transportation and can lead the mucus to dry out and crust, which can lead to symptoms of irritation and blockage in the nose.
As you can see, the nose and sinuses are intimately related. Their lining wallpaper appears to be the same and they react to inflammation as one unit. For this reason, many experts have advocated the term “rhinosinusitis” as a more accurate description of what is truly going on in the nose (Greek for nose is rhin, as in rhinoceros) and sinuses.
How is sinusitis diagnosed?
Symptoms of sinusitis can be quite variable, both in whether or not they are present and how severe they are. They can mimic many other conditions, including the common cold, allergies, migraines, and other types of headaches and jaw problems. Patients with sinusitis typically have at least one of the following symptoms:
- Discolored nasal discharge, often yellow or green
- Facial fullness, heaviness, or congestion
- Facial pain or pressure
- Decrease in or loss of the sense of smell (the sense of taste may also be affected)
- Decrease in the ability to breathe through the nose
Other symptoms that patients may have in association with the ones above are the following:
- Fever, often low grade and variable
- Fatigue or malaise (flu-like symptoms)
- Pain in the upper teeth
- Pressure or fullness in the ears
- Chronic cough
- Bad breath
- Nasal dryness and crusting of secretions
Clearly, these symptoms are not specific and could be from a number of conditions. It is for this reason that sinusitis can be difficult to diagnose. Fortunately, recent diagnostic advances have improved our ability to accurately identify patients with sinusitis so that they can be appropriately treated.
Because the symptoms of sinusitis can mimic other diseases, a careful history of the problem is important. While facial pain and discolored nasal discharge or mucus is most often associated with sinusitis, other more subtle symptoms like cough, malaise, or fatigue should also be sought out. Questions about each specific symptom, including its duration and severity, and about the success or failure of past interventions can help to shed light on the nature of the problem. In order to be thorough and complete, we use a questionnaire to gather information about a patient's symptoms. The patient's responses then form a basis for a more thorough discussion of the history of the illness. An equally thorough physical examination is then conducted.
Because symptoms within the nose and sinuses can be associated with findings within the ears, throat, and neck, a complete otolaryngological (ENT) examination is done. Often a more thorough examination of the nose, called a diagnostic nasal endoscopy is performed. This procedure involves passing a fiber-optic telescope, or endoscope, into the nose and examining the interior of the nasal cavity. In this manner, the condition of the mucosal lining surrounding the sinus openings can be examined. Nasal endoscopy has greatly advanced the diagnosis and treatment of sinusitis. By providing superb illumination and magnification, it gives physicians the ability to closely examine conditions deep within the nose. It allows precise identification and targeting of problem areas and gives physicians an increased ability to monitor a patient's response to therapy.
Despite the great advances brought about by nasal endoscopy, this procedure can only give information about the openings of the sinuses. Unless a patient has had previous sinus surgery, the examiner cannot see the interior of the sinuses. Even in patients who have had sinus surgery, scarring can obscure the view into the previously opened sinuses. For this reason, another tool is used to visualize the sinus interior: computerized tomography, also known as a CT scan.
The CT scan provides information about swelling within the sinuses and also provides a road map of sinus anatomy should surgery be necessary. CT scanning can be a powerful tool in diagnosing sinusitis but must be performed under the right conditions. In patients with chronic sinusitis, the procedure should be performed when the patient’s symptoms are relatively quiescent. Patients should have received appropriate medical therapy and the scan should be performed no sooner than four weeks after the last flare-up. Otherwise, residual acute (short-term) inflammation will show up on the CT scan and give a false impression about the severity of the disease. If a patient undergoes a scan during an acute flare of sinusitis—or even during an episode of the common cold—the scan may show inflammation that may completely resolve. Such inflammation does not necessitate long-term medications and especially does not require surgery.
CT imaging must therefore be interpreted in the context of the each patient’s overall condition. All components of each patient's assessment—history, general otolaryngological examination, nasal endoscopy, and CT scanning—must be considered before choosing a course of treatment. Trying to use just one without the others can lead to errors in diagnosis and delays in instituting the correct therapy.
What is the difference between acute and chronic sinusitis?
- Acute Sinusitis - When symptoms of sinusitis are present for less than four weeks, it is defined as acute sinusitis. Acute simply refers to the time course, not the severity of the symptoms. Typical acute sinusitis is caused by bacteria and will often follow a viral upper respiratory infection (common cold). The inflammation and swelling in acute sinusitis usually resolved completely or nearly completely following effective treatment. Patients who have multiple episodes of acute sinusitis with resolution of symptoms in between are said to have “recurrent acute sinusitis” and may benefit from interventions aimed more at prevention of the repeating episodes.
- Chronic Sinusitis - Some patients have continued symptoms that wax and wane but never completely go away. When these symptoms are present for over three months, these patients are said to suffer from chronic sinusitis. While acute sinusitis is primarily a relatively short-lived bacterial infection, chronic sinusitis is different in many ways. Inflammation, rather than infection with bacteria, appears to play a larger role in causing chronic sinusitis and the treatment of chronic sinusitis therefore differs from the treatment of acute sinusitis.
What causes sinusitis?
This answer to this question differs for acute and chronic sinus problems.
Acute Sinusitis - In acute sinusitis, an inflammation typically occurs in the nasal cavity, which then spreads to the sinuses. When we have inflammation in the nose and sinuses (from colds, allergens, bacteria, irritants, and others) a few changes occur. First, as we all know, we produce more mucus and it often gets thicker. These changes overcome the mucosa cilia’s ability to transport the mucus and it starts to accumulate in the sinus rooms or in the nasal cavity hallway. The mucus may begin to accumulate cells and proteins from the immune system, which can begin to change the color of the mucus. For this reason, a change in the color of the mucus doesn’t always mean there is a bacterial infection.
Inflammation in the nose and sinuses also causes the mucosa/wallpaper lining to swell. Because the openings between the sinuses/rooms and the nasal cavity/hallway are so small, this swelling can block off the openings. When this happens, the air in the sinuses can’t exchange and the mucus becomes trapped. Bacteria that normally exist in the nose and throat can get into the sinuses and infect the mucus there, causing acute bacterial sinusitis. Air circulation into and out of the sinuses is also impaired.
With further inflammation, the movement of mucus out of the sinuses by the microscopic hairs called cilia slows and the secretions become stagnant. These conditions favor growth of bacteria and an infection sets in. Once the bacterial infection begins, it causes more inflammation and swelling and leading to increased mucus production. More swelling only worsens the mucus transport and air exchange, favoring more bacterial growth and the cycle continues.
Chronic Sinusitis - Formerly we thought chronic sinusitis was a longer version of acute sinusitis, but recently this has changed. Instead, it appears that chronic sinusitis is more of an inflammatory disorder that from time to time has bacterial flare-ups. The bacteria, however, may not always be driving the inflammation. They may be the effect of impaired transport of the mucus, taking advantage of the mucus that accumulates because of the inflammation, rather than originally causing it.
The next question then is what is causing the inflammation in the first place? The answer to this question is not clear and there may actually be multiple answers. Chronic sinusitis may have one cause in some patients and another cause in others. Some patients may have multiple causes present. Researchers have found an association between chronic sinusitis and a number of conditions, including fungus, bacterial proteins called superantigens, allergies, viruses, and acid reflux. It isn’t always clear in patients which of these factors is present and whether they are the cause or effect of the sinus inflammation. Many researchers feel that finding the answers to these questions is the key to unlock the effective treatment of chronic sinusitis, since we can’t fully treat or prevent a disease when we don’t know the cause or causes.
What are polyps?
A polyp by definition is an outgrowth from a tissue, shaped like a little bit like a teardrop. Depending on the tissue, however, they can have significantly different implications. Polyps in the intestines are often removed because there is a concern they may develop into cancer. This is almost never the case in sinus polyps. Sinus and nasal polyps indicate a more severe form of chronic sinusitis. The polyps typically start in the sinuses and may grow out into the nose (from the rooms into the hallway). When severe, they can completely block the airflow through the nose. Patients with nasal polyps frequently have asthma as well and may be sensitive to aspirin and similar anti-inflammatory products. Like other forms of chronic sinusitis, it’s not entirely clear why some patients get polyps, hampering our ability to completely rid patients of them.
Do I have allergies?
Allergies affect 16 percent of Americans and are seen much more commonly in patients with chronic sinusitis. Allergy symptoms are caused by the body’s reaction to allergens, which are proteins produced by insects, animals, plants, and molds. These allergens can be divided into two large classes based on when they are present. Perennial allergens are present year round. They include mold, animal dander, and dust (actually we’re allergic to the microscopic insect called the dust mite). Seasonal allergies are present for shorter periods of time, often repeating each year at the same time. Pollens from trees, grasses, and weeds are the best example of these seasonal allergens.
Patients with allergies can have classic symptoms including itchy nose or eyes, sneezing, watery eyes, and nasal congestion. These symptoms typically occur within a few minutes after exposure to the allergen in sensitive individuals. When patients are more or less constantly exposed to allergens, they react in a different way. They may not experience the typical itching and sneezing symptoms, but may have chronic congestion, runny nose, and fatigue. Often the allergic response to an irritant results in sufficient inflammation within the nose to precipitate or worsen the sinus condition.
Identifying and treating allergies is important in reducing inflammation that can affect the nose and sinuses, which can predispose individuals to sinusitis. By identifying the allergens a patient is sensitive to through allergy testing, patients may be able to avoid or limit their exposure to them. Medications to block the allergic reaction can be helpful, as can allergy shots, which have the potential to permanently blunt the body’s allergic reaction to the allergens in the shots.
How is sinusitis treated?
The goal in treating sinusitis is to re-open the narrow areas between the sinuses and the nasal cavity (to keep the doorway from the rooms into the hallway open) and to reestablish the normal movement of secretions along the nasal and sinus lining (the special wallpaper lining the rooms. This in turn promotes movement of mucus out of the sinus and re-establishes normal oxygen levels within the sinuses. The principal way to accomplish these goals remains medications. In some patients, medical therapy fails to provide relief of their symptoms and these patients may be considered for surgery. Often the treatment of chronic sinusitis involves combining a number of medications. Each type of treatment is summarized below.
- Steroid nasal sprays - This class of medications works to diminish the nasal lining's inflammatory response, resulting in less swelling and better mucus transport. These sprays form the first in the treatment of chronic sinusitis as well as a number of other inflammatory conditions within the nose. They are typically sprayed into both sides of the nose and work directly on the lining they come into contact with. Their onset of action is relatively slow and patients may not feel their effect for days or weeks. For this reason, some patients give up on this method of treatment too soon.
Steroid nasal sprays are generally well tolerated. Side effects from these medications include irritation within the nose and nasal bleeding. This bleeding can be avoided by pointing the spray bottle away from the nasal septum (the bone and cartilage that runs down the middle of the nasal cavity). Because the sprays are minimally absorbed throughout the rest of the body, side effects seen with taking steroid pills (see below) are extremely rare.
- Antibiotics - The vast majority of cases of acute sinusitis are due to bacteria. For this reason, antibiotics are a mainstay of treatment for the acute form of sinusitis. Acute flare-ups of symptoms in chronic sinusitis are also likely to be caused by bacteria, while their role in the long-term symptoms of chronic sinusitis is more speculative.
For acute sinusitis, a seven to ten day course of antibiotics is usually effective, although more recently a number of shorter duration antibiotic regimens have been developed. For patients with the underlying inflammation of chronic sinusitis, however, the nose and sinuses may take longer to respond. In these patients, three to four weeks of antibiotics, or even longer, may be necessary to treat an acute exacerbation of their chronic sinusitis.
Most patients with chronic sinusitis have previously been on many short courses of antibiotics, usually not enough to stamp out the bacteria in a chronically inflamed sinus. In patients who do not respond well to antibiotics, a culture can be quite helpful. In this circumstance a sample of the bacteria is sent to the laboratory for identification and other testing. Because the openings of the sinuses cannot be seen without an endoscope, blind sampling of the nasal cavity using conventional equipment is nearly useless. Nevertheless, endoscopically directed cultures have proven very useful.
Antibiotics have a number of side effects, many of which are specific to each different type of drug. Nevertheless, some are common including rash and diarrhea. If these occur, the drug should be discontinued and the symptoms immediately reported to your physician. While most reactions are mild, some can be serious and may require additional medical attention. Some antibiotics have been shown to have positive side effects, at least in the test tube. This class of antibiotics, called macrolides, includes erythromycin, clarithromycin, and azithromycin and is suspected to decrease inflammation in the nasal cavity and sinuses, independent of its antibacterial effect. For this reason, many physicians chose to treat patients with one of these drugs, especially in chronic sinus exacerbations.
- Saline irrigations - Some physicians advocate rinsing the nose with saline or other solutions. Research done here at the University of Utah and at other institutions have demonstrated that irrigation is one of the most effective methods of reaching the sinuses, probably more effective than sprays or nebulizer machines. Saline or other solutions are most effectively delivered with a squirt bottle that can be regularly cleaned. Machines like pulsatile dental irrigators adapted for use in the sinuses are difficult to keep clean and are suspected to introduce bacteria into the sinuses.
Many experts recommend using distilled water for irrigations or tap water that has been boiled. Irrigations can assist in removing thick or dried mucus and can help keep the nose and sinuses cleaned out when the normal mucus transport system is not working well. In cases of frequent or persistent infections, antibiotics can be added to the solution.
- Saline nasal spray - Like saline irrigation, nasal saline (salt water) has been theorized to improve mucus transport. While there are few studies to support this claim, saline sprays are relatively innocuous and inexpensive. They appear to be helpful in some patients, especially those with dryness or crusting as a major symptom. Other sprays, which have various glycerin and herbal additives, are particularly helpful in relieving nasal dryness. Frequent use of saline nasal sprays is useful after sinus surgery to keep the secretions within the nose moist and prevent crusting.
- Antihistamines - Antihistamines combat the allergic response within the nose. Blocking this allergic response can improve sinus function and reduce symptoms of sinusitis. One problem with many older antihistamines is the fact that they can cause sedation as well as drying and thickening of nasal secretions. Many new antihistamines have little or no sedative side effects and don't cause problems with secretions. Some are also combined with a decongestant to further reduce swelling within the nose and sinuses. While most antihistamines come in the form of pills taken once or twice a day, others can be sprayed into the nose or come as eye drops to control specific symptoms.
- Decongestants - Decongestants act specifically to decrease swelling within the nose. They work directly on the blood vessels within the nose that control the thickness of the lining. They may also affect blood vessels throughout the body and should be used with caution (if at all) in individuals with certain disorders that are particularly difficult to control, such as hypertension (high blood pressure). Most decongestants are available over the counter and they are often combined with antihistamines. They can cause jitteriness or difficulty sleeping for some patients and should not be used in men with prostate problems.
You should be careful with decongestant nasal sprays. They are particularly useful in diminishing swelling within the nose for a short period of time. If used for more than three days in a row, they can lead to a rebound effect and actually worsen nasal swelling. Often patients will then increase the dosage or the frequency with which they use the sprays in order to diminish the rebound swelling. This leads to a cycle of decongestion followed by rebound swelling, a condition known as rhinitis medicamentosa.
- Mucolytics - These drugs, also known as expectorants, are common ingredients in cough syrups and cold remedies because of their ability to loosen and thin mucus. Because mucus often becomes thick and stagnant in sinusitis many physicians believe these medications may be helpful in this condition as well. The mucolytics are usually well tolerated with almost no side effects. In higher doses they can cause nausea, and, because these drugs act to thin mucus, they can increase fertility in women.
- Leukotriene antagonists - These drugs are a newer class of drugs approved to treat asthma and allergies. They inhibit the leukotriene pathway, a series of chemical reactions in the body involved in inflammation. These drugs have proven successful in diminishing sinus inflammation in some patients but these effects can take some time to develop and don’t occur in all patients. Rarely they can cause problems with liver function and, depending on which drug in the class is chosen, it may be necessary to monitor the liver with periodic blood tests.
- Oral steroids - In severe cases of chronic sinusitis, oral steroids (steroid pills taken by mouth) may be used. By increasing the delivery of the steroid drug to the nasal and sinus tissues, these drugs augment the action of the nasal steroid sprays in decreasing the inflammatory response. While they are quite effective, because these drugs are taken in pill form the medication spreads throughout the body and may have significant side effects. These include osteoporosis, liver abnormalities, cataracts, glaucoma, weight gain, emotional changes, and joint problems. With the exception of emotional changes and weight gain, most of the side effects are rarely seen unless the drug is used for a prolonged period of time. Rare idiosyncratic reactions severely affecting the hip and shoulder joints have been reported.
Oral steroids are often given to patients with nasal polyps or asthma in preparation for surgery. They may be continued for a few weeks following the procedure to diminish the inflammatory response during healing.
What about other nasal and sinus conditions?
A number of other conditions can affect the nose and either mimic or contribute to sinusitis (such as allergies). Patients who have facial pain as a primary component of their symptoms may not have sinus problems at all. Numerous headache and facial pain problems mimic sinus disease and can be nearly impossible to differentiate based on symptoms alone. Only a thorough evaluation, sometimes including nasal endoscopy and/or sinus imaging can rule in or rule out a particular diagnosis.
Nasal airway obstruction - When patients find it difficult to breathe through their noses, physicians label this condition nasal airway obstruction. Because of the nose’s ability to warm, humidify, and remove particles from the air before it goes into the lungs, we are naturally nose breathers. Nasal airway obstruction can cause discomfort due to the need to breathe through the mouth, leading to a dry mouth and throat irritation. It may also contribute to snoring or its more serious cousin, obstructive sleep apnea. Nasal airway obstruction can also result from swelling of the lining within the nose (the mucosa), from structural narrowing within the nose, or both. Medications to control the mucosal swelling are often effective in relieving the sense of obstruction.
When the problem is a structural one, often surgery is necessary to resolve the problem. The first step in resolving a structural narrowing is defining the location of the obstruction. Earlier we referred to the nose as a hallway through which air passes from the outside environment on its way in and out of the lungs. This hallway has shelves that hang off of the walls, called turbinates and also has a narrowing at its beginning, called a nasal valve. Narrowing or collapse of this valve or enlargement of the shelf-like turbinates can impede the movement of air through the nasal hallway. Moreover, there is a wall that runs the length of the hallway and divides it into more or less equal halves. If the wall, the septum, is crooked, the air will not pass down the hallway properly, also giving the sensation of nasal obstruction. This condition is called a deviated septum. Straightening of the septum can often lead to improvements in nasal airflow through the nose. This is called a septoplasty.
Occasionally removal of some of the turbinate tissue may also be advantageous. Called an inferior turbinate reduction, this can typically be performed in the office under local anesthesia with return to normal activities the same day.
Rhinitis medicamentosa - Nasal decongestant sprays are effective ways of diminishing swelling within the nose. Nevertheless, when used for more than three days in a row, they can lead to worsening of the swelling. This occurs because of a rebound effect that occurs as the spray wears off. Increasing the frequency of use only worsens the condition, and may lead to more serious consequences. Treatment is relatively simple: complete discontinuation of the nasal decongestant sprays. Because this course of action often results in severe rebound swelling, other medications to diminish swelling can be prescribed by your physician to assist in getting through this short-term recovery phase.
What is a septoplasty?
The septum is a wall that divides the left nasal cavity from the right. Ideally it should run down the middle of the nasal cavity but often it deviates to one side or the other.
This condition is called a septal deviation and can make breathing through the nose difficult, either because of actual obstruction of flow, or because of the creation of turbulent airflow, which slows the air movement. In these cases, a septal repair, or septoplasty, is recommended.
The procedure is typically performed through the nose. An incision is made within the nose, and the lining is lifted off of the crooked cartilage and bone. These structural elements are then straightened in a variety of ways and the lining is then returned to its original place. Dissolvable stitches are used to keep the lining in place during healing. Occasionally plastic splints may need to be placed temporarily within the nose following surgery.
In some severe deviations, or when other surgery is to be performed on the nose at the same time, a small incision between the nostrils may be necessary. If an external incision is to be made, your surgeon will specifically discuss this issue with you.
In some patients, other structures in the nose may contribute to the blockage of airflow and your surgeon may advise that these be addressed as well. Occasionally, shelf-like structures known as turbinates can be enlarged and block normal air movement through the nose. The function of the turbinates is to increase the surface area of the nose and to act like battens to direct air through the nose. Surface area within the nose is important because the nose warms and humidifies air and removes small particles before the air reaches the lungs. When the turbinates are too large, however, they can disrupt air movement through the nose and may therefore need to be reduced in size. Your surgeon will discuss with you whether this is the case in your nose.
What are the benefits of surgery?
The goal of the surgery is to restore normal airflow through the nose. Deviated portions of the nasal septum will be straightened in order to remove blockages and portions that cause turbulent airflow. Trimming of enlarged turbinates may also play a role in achieving this goal.
What are the risks of surgery?
While the risks involved in this surgery are relatively minor and uncommon, it is important to remember that risks do exist, as they do in all activities in life. You should be aware of the risks of the surgery in order for you to make an informed decision. All surgeries carry with them the risks of bleeding, infection, and pain. The risk of bleeding is increased by certain medications so you should review all medications (prescription, over-the-counter, and herbal) with your physician prior to surgery.
Aspirin must be stopped at least 10 days prior to surgery and other anti-inflammatory medications, such as ibuprofen (Motrin, Advil,) must be stopped at least four days prior to surgery. In rare cases of excessive bleeding, small sponges may be placed at the conclusion of the procedure. These sponges are usually removed within one to two days.
Taking antibiotics after the procedure will minimize the risk of infection. Extra Strength Tylenol or a mild narcotic and Tylenol combination relieves most patients’ pain. You will receive a prescription for sufficient pain medicine after your surgery.
Rarely, septal surgery can lead to an unexpected change in the appearance of the nose or can lead to a permanent loss of the sense of smell. Another rare risk is creation of a hole in the septum, connecting the right side of the nose to the left.
This condition, called a septal perforation, can cause accumulation of dry mucus (crusting), bleeding, or a whistling sound in the nose. Because the nose is close to the eyes and brain, it is conceivable that these structures could be injured during nasal surgery as well. This is extremely rare.
Turbinate surgery carries the additional risks of increased crusting and a condition called atrophic rhinitis or ozena, in which the interior of the nose is excessively dry. Atrophic rhinitis is caused by the loss of moisturizing surface area in the nose and can be difficult to treat. Lack of improvement or even worsening of the underlying condition and the need for re-operation are other risks inherent with any surgery. Surgery also carries with it the risks of anesthesia. Septoplasty can usually be performed under local or general anesthesia. You should discuss your anesthesia preferences with your surgeon in order to determine what is best for you. You will also have an opportunity to discuss the risks and benefits of each form of anesthesia with an anesthesiologist.
What are the alternatives?
Medications to diminish the swelling of the lining of the nose may promote airflow but have drawbacks that you should discuss with your physician. If turbinate surgery is recommended, there are a number of methods to perform this portion of the procedure and you may wish to discuss these with your surgeon. The surgery is, of course, elective so that no surgery is also an option. As with any surgery, you should feel comfortable seeking a second opinion from another surgeon.
What should I expect after surgery?
- Healing - The majority of the healing in your nose will take place over the course of four to six weeks. In patients with allergies or over-reactive nasal and sinus lining, the process can take much longer. During this time, you will want to keep your nose out of dusty or smoky environments. This includes tobacco smoke.
- Medications - Following your surgery you will receive prescriptions for a number of medications. Typically these include pain medicine and antibiotics. It is essential that the prescriptions be filled promptly and the medications taken as directed. Crusting of blood and mucus can slow the healing process. In order to keep your nose moist and prevent the crusting, you should use saline (salt-water) nasal spray for at least two weeks following surgery. These sprays can be purchased over the counter at your pharmacy. For the first five days following surgery, you should use the spray at least once an hour while you are awake. Thereafter, you can reduce use to four or five times a day. However, you cannot over-do it with the salt water, so use it more frequently if you wish.
- Fatigue - Fatigue for two or three days following the surgery is common. Patients who have general anesthesia often find the fatigue can hang on for an extra day or two. You will want to take it easy for a few days following surgery. You should also avoid strenuous physical activity for a few days. Moderate activity (like going for a walk) is acceptable.
- Work - Most individuals return to work within four to seven days following surgery. Some return earlier, some later. Plan to be out for a week and return as soon as you feel up to it.
- Travel - Many of our patients come from some distance. We prefer you stay in the local area overnight following the surgery. If necessary, you may travel by air after the surgery.
- Post-operative visits - Depending on the extent of your septal surgery, expect to see your doctor within the first three weeks after surgery and, if necessary, another visit four to six weeks later.
What are a few things to be aware of?
- Bleeding - Oozing from the nose is common for 24–48 hours following surgery. You should probably put an old pillowcase on your pillow or put a towel over it. Additionally, you may want to sleep with your head elevated on an extra pillow to minimize the oozing. After a couple of days, the discharge from your nose may turn maroon or dark brown. This change is due to old blood and is normal. It does not mean that the nose or sinuses are infected.
Occasionally, persistent bleeding from the nose can develop. If this occurs, sit upright and breathe through your nose for 5–10 minutes. This should relieve most bleeding. If it does not, or if the bleeding is heavy, contact our office.
- Nausea - Nausea and even vomiting following general anesthesia are not uncommon. They can also occur after local anesthesia, but less often. The nausea usually fades after about 12–24 hours. Try to sip liquids to avoid dehydration during these periods. If the nausea is severe notify our office.
- Crusting - During septal surgery, incisions are made inside the nose. Like incisions on the external skin, scabs will form as these heal. Mucus may also accumulate on these crusts and block breathing through your nose. Do not attempt to remove these, but instead continue to use the saltwater nasal spray to soften the crusts. If the problem is severe, your physician may prescribe other treatments.
- Pain - Some discomfort following the procedure is to be expected but usually is not especially severe. Use the pain medicine as needed. As soon as you feel ready, try to switch to an over the counter pain medicine like extra-strength Tylenol. For the first two to three weeks after surgery, do not use medications that contain aspirin, Ibuprofen, or other anti-inflammatory compounds, as these promote bleeding. Sometimes after anesthesia, your muscles may ache all over like you have lifted weights or strained muscles, particularly in the first day or two after surgery. Take Tylenol for this and stretch your muscles—it will subside.
What are the “don’ts?”
- Nose blowing - You may sniff (even vigorously) if you feel you need to clear your nose. Realize that the interior of the nose will be swollen for four to seven days and may not clear—even with the most forceful attempts. Blowing your nose too early in the healing process can cause bleeding. You may begin to blow your nose lightly three days after surgery.
- Bending, lifting, straining - Placing your head below your waist (to do things like tie your shoes), lifting anything over 10 pounds (including children) and straining will all increase the risk of bleeding. You should avoid these activities for one full week following surgery.
When should I call a doctor?
Promptly report the following symptoms to your doctor:
- Fevers (100.6 or higher)
- Any symptom of infection: marked swelling of the tip of the nose, or redness with increasing tenderness at the tip of the nose
- Severe headache accompanied by nausea, vomiting, or unusual change in your behavior
- New rashes
- Swelling or bruising around the eyes
What are the benefits of surgery?
The goal of endoscopic sinus surgery is to improve the drainage of the sinuses and prevent mucus from building up in these chambers. When secretions accumulate in a blocked off sinus, they may become infected with bacteria and result in a flare up of sinus symptoms. By widening the natural drainage pathways of the sinuses, surgery helps to decrease the frequency, severity, and duration of infections.
It is important to understand that surgery is not a cure for sinusitis. In most patients with sinusitis, the lining of the nose and sinuses (the mucosa) overreacts to irritants, swells, and causes accumulation of mucus. Sinus surgery does not directly treat this over-reactive lining, but instead drains the sinuses and allows the mucosa to improve on its own. However, due to allergy or irritant stimulation, the lining may remain inflamed after surgery. This is typically the case, so medications like nasal sprays and antihistamines remain essential after surgery.
Opening the sinus cavities more widely allows the spray medications to get into the sinuses and directly act on all of the mucosa. It also promotes drainage of mucus so that irritants are removed from the nose. Surgery, therefore, acts with medications to improve the lining and keep the sinuses healthy. It is an adjunct to, not a replacement for, proper medical management.
What are the risks?
Surgery, like all events in life, has some risks. Your surgeon has spent years developing his technique to minimize these risks and also teaches others how to do the same. Nevertheless, you should be aware of the potential risks of the surgery so you can make an informed decision. All surgeries carry with them the risks of bleeding, infection, and pain. The risk of bleeding is increased by certain medications so you should review all medications (prescription, over-the-counter, and herbal) with your physician prior to surgery.
Aspirin must be stopped at least 10 days prior to surgery and other anti-inflammatory medications such as ibuprofen (Motrin, Advil) must be stopped at least four days prior to surgery. Rarely, excessive bleeding requires the use of nasal packing or may even force termination of the procedure. In extremely rare cases, blood transfusion may be required. If a transfusion is necessary, it carries the risk of transfusion reaction as well transmission of blood-borne disease.
Taking antibiotics after the procedure will minimize the risk of infection. The length of antibiotic treatment is individualized based on endoscopic findings but usually lasts two to four weeks. Most patients’ pain is relieved by extra strength acetaminophen (for example, Tylenol) or a mild narcotic and acetaminophen combination. You will receive a prescription for sufficient pain medicine after your surgery. Some scar tissue develops after any surgery, but if it is excessive it may obstruct the newly opened sinuses. You should expect to visit your surgeon multiple times during the initial post-operative period. This post-operative care is critical to the success of the surgery and usually requires visits every week or every other week for four to six weeks. During these visits, your nose and sinuses will be thoroughly examined to be sure it is healing properly and that excessive scarring is not developing. Sometimes it is necessary to remove a small amount of scar tissue under local anesthesia.
Some temporary swelling or bruising around the eye may occur after surgery. Tears may run from the eye for a few days after surgery. This is usually temporary but in rare cases may persist. If so, this condition can typically be corrected with minor surgery.
In some cases it is necessary to straighten the nasal septum in order to gain access to the sinuses or to improve breathing through the nose. This procedure, called a septoplasty, carries with it the additional risks of a permanent hole in the septum (septal perforation). Rarely septoplasty can change the appearance of the nose or cause permanent numbness of the front top teeth. Nasal surgery, in rare cases, can also lead to loss of the sense of smell.
Lack of improvement or even worsening of the underlying condition and the need for re-operation are other risks inherent with any surgery. Surgery also carries with it risks of anesthesia. Endoscopic sinus surgery can usually be performed under either local or general anesthesia. You should discuss your anesthesia preferences with your surgeon in order to determine what is best for you. You will also have an opportunity to discuss the risks and benefits of each form of anesthesia with an anesthesiologist.
What are the alternatives?
Continuing with medical therapy alone and avoiding surgery is always an alternative. Additionally, other types of sinus surgeries exist and you may wish to speak with your surgeon about them. As with any surgery, you should feel comfortable seeking a second opinion from another surgeon.
What should I expect following surgery?
Healing - The majority of the healing in your nose will take place over the next 4-6 weeks. In patients with nasal polyps and severe mucosal hyperreactivity (over-reactive nasal and sinus lining), the process can take much longer. During this time, you will want to keep your nose out of dusty or smoky environments as much as possible. This includes tobacco smoke.
Medications - Following your surgery you will receive prescriptions for a number of medications. Typically these include pain medicine and antibiotics. In some cases, patients will be on steroid pills after the surgery. It is essential that the prescriptions be filled promptly and the medications taken as directed. These medications are essential components of your care, promoting rapid and correct healing. Failure to take them properly can lead to post-operative infection and scarring within your sinuses.
The medications will be adjusted based on the progress of the healing. This will be assessed by examining your nose during your visits following surgery. Some medications will be continued, some will be stopped, and other new ones will be started. Do not stop the medications on your own without speaking to your physician. You may restart your nasal steroid sprays one week after the surgery. If you have a question, please contact the office. We want to make sure the healing progresses appropriately and that the surgery is a success.
Irrigating - Crusting of blood and mucus can slow the healing process. In order to keep your nose moist and prevent the crusting, you should use saline (salt-water) nasal irrigation for at least two weeks following surgery. A simple system to use is NeilMed’s Sinus Rinse, which can be purchased or ordered over the counter at many pharmacies.
For the first five days following surgery, you should irrigate your nose two to three times a day. Try to irrigate as forcefully as you can to clear out as much of the dried blood and mucus as possible. If your nose feels dry or stuffy between irrigations, you can also use saline nasal spray. Try to keep the inside of your nose as moist as possible. The more you use the saline irrigation and spray, the easier the postoperative visits will go.
Fatigue - Fatigue for two or three days following the surgery is common. You will want to take it easy for a few days following surgery. You should also avoid strenuous physical activity for a few days. Moderate activity (like going for a walk) is acceptable.
Work - Most individuals return to work within a week following surgery. Some return earlier, some later. Plan to be out for a week and return as soon as you feel up to it.
Travel - Many of our patients come from some distance. We prefer you stay in the local area overnight following the surgery. If necessary, you may travel by air 48 hours after the surgery.
Post-operative visits - The care of your sinuses does not end when the surgery is completed. Frequent postoperative visits over the course of four to six weeks are another important component of your treatment. During these visits, your physician will examine your nose with a nasal telescope (similar to before your surgery) and ensure the healing is progressing. Debridement (removal of dried blood and mucus) may also be necessary while the nose regains its ability to care for itself. In some cases, small revisions and adjustments of the healing under local anesthesia are necessary to ensure scar tissue does not obstruct the sinuses.
Since your nose will be tender for a few weeks following the surgery, we recommend that you take one or two tablets of the pain medicine about 30 minutes prior to your visit. Because the medicine contains a narcotic, you will need to have someone drive you home after the visit. Taking the medicine before the visit allows most patients to undergo the exams with minimal discomfort.
What are a few things to be aware of?
Bleeding - Oozing from the nose is common for 24–48 hours following surgery. It may occur for 12–24 hours after each post-operative visit also. You should probably put an old pillowcase on your pillow or put a towel over it. Additionally, you may want to sleep with your head elevated on an extra pillow to minimize the oozing. After a couple of days, the discharge from your nose may turn maroon or dark brown. This change is due to old blood and is normal. It does not mean that the nose or sinuses are infected.
Occasionally, persistent bleeding from the nose can develop. If this occurs, sit upright and breathe through your nose for 5–10 minutes. This should relieve most bleeding. If it does not, or if the bleeding is heavy, contact our office.
Nausea - Nausea and even vomiting following general anesthesia are not uncommon. They can occur after local anesthesia too, but less often. The nausea usually fades after about 12–24 hours. Try to sip liquids to avoid dehydration during these periods. If the nausea is severe notify our office.
Pain - Some discomfort following the procedure is to be expected but usually is not especially severe. Use the pain medicine as needed. As soon as you feel ready, try to switch to an over the counter pain medicine like extra-strength acetaminophen (for example, Tylenol). For the first two to three weeks after surgery, do not use medications that contain aspirin, ibuprofen, or other anti-inflammatory compounds as these promote bleeding. Medications containing acetaminophen are best during this stage of healing. Remember to take your prescription pain medicine prior to your first couple of post-operative visits.
Sometimes after anesthesia, your muscles may ache all over like you have lifted weights or strained muscles, particularly in the first day or two after surgery. Take over the counter pain medicine for this and stretch your muscles—it will subside.
What are the“don’ts"?
Nose blowing - You may sniff (even vigorously) if you feel you need to clear your nose. Realize that the interior of the nose will be swollen for two to three days and may not clear—even with the most forceful attempts. Blowing your nose too early in the healing process can be dangerous. You may begin to blow your nose lightly three days following the surgery.
Bending, lifting, straining - Placing your head below your waist (like tying your shoes), lifting anything over 10 pounds (including children) and straining will all increase the risk of bleeding. You should avoid these activities for one full week following surgery.
Swimming - While the nose heals, pool and lake water can inflame or infect it. You should not swim for at least four weeks following surgery.
When should I call a doctor?
Promptly report the following symptoms to your doctor:
- Severe headache accompanied by nausea, vomiting, or unusual change in behavior
- Any change in vision, including blurring or double vision
- Light causing pain in your eyes
- Swelling or bruising around the eyes
- Fever (100.6 degrees or higher)
- Stiffening neck
- New rashes
- Clear, watery discharge from your nose
What is in the anterior skull base?
The anterior skull base joins the brain or cranial cavity to three important bone structures: orbits, the nasal cavity, and paranasal sinuses. The orbits are the sockets that contain the eyes. While they may look like simple cavities, they actually are made up of seven different bones that all come together to form a pyramid-shaped structure on its side. The nasal cavity is the double hallway we breathe through, often simply referred to as the nose. It’s not the same shape as the nose on the outside, however. The level of the bone separating the brain cavity and the nasal cavity is at the bridge of the nose, between the corners of the eyes. The sinuses are hollow chambers placed within the bones of the face. They are located next to the nasal cavity and are therefore named the paranasal sinuses.
What is anterior skull base surgery?
In anterior skull base surgery, we take advantage of how close the brain is to the nose and sinuses. We can often access many areas of the bottom of the brain through the nasal and sinus cavities. Skull base surgery is typically performed by a team of surgeons, each with his or her own expertise. Because lesions being treated usually involve the brain, a neurosurgeon is typically involved. Otolaryngologists (ENT surgeons) work with the neurosurgeon to provide the approach to the skull base and remove parts of the lesion. This otolaryngologist may be a sinus specialist in the case of access through the nose and sinuses or a head and neck oncologic or cancer surgeon for larger tumors. A facial plastic/reconstructive surgeon may be involved to assist with restoring form and function after some surgeries. An ophthalmologic (eye) surgeon may also be involved in some cases. The challenge of skull base surgery is to access a deep-seated area with minimal effect on normal structures of the face, eyes, and ears.
Over the past decade, an increasing emphasis on minimally invasive techniques has resulted in numerous techniques that cause either small incisions or no external incisions at all. Many factors determine which techniques are most appropriate for each patient.
Am I a candidate for minimally invasive anterior skull base surgery?
The answer to this question depends on many factors and can only be answered after a thorough evaluation by a surgeon experienced in minimally invasive skull base surgery.
To arrange a consultation, phone the ENT clinic at 801-587-UENT (801-587-8368).
Otolaryngology, Head & Neck Surgery, Sinus and Rhinology, Surgical Oncology, Vasculitis
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