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What Happens After You Check In for Sinus Surgery?
Interviewer: So you're scheduled for a sinus surgery, and that's often done endoscopically. You may not remember much of the day, but if you're curious about what is going to happen from the waiting room to the recovery, this piece might be for you.
Today, we're joined by Dr. Kristine Smith, a fellowship-trained rhinologist at University of Utah Health.
Now, Dr. Smith, let's walk through the day, step-by-step, and kind of set expectations for our listeners so that they can feel more prepared on the day of surgery. What happens right after they check in?
Meeting Your Surgical and Anesthesia Team Before the Procedure
Dr. Smith: So usually right after you check in, next thing that will happen is that you'll go to our preoperative area in the hospital, and this is typically a space where there'll be a private room or a private bed where you're going to get ready for surgery and meet the team that's going to take care of you on that day.
This is the place where you're typically going to change into one of our very fancy hospital gowns, and where our nurse will also usually start an IV while you're waiting to see your surgeon, your anesthesiologist, and your nurse that morning.
Interviewer: Once you are in that room, after they've kind of maybe run the lines, etc., where do they go from there?
Dr. Smith: Once you're dressed up and ready to go, the team is going to make sure that they pop in and say hi the morning of, typically to check and see if you have any questions about your anesthesia or your surgery, and also to do a bit of a health check to make sure that everyone is up-to-date on the team about where you're at to keep you safe on that day.
And then once all of those things have happened, specifically once your consents have been signed for surgery, then we're going to get ready to roll you back to the operating room.
When Anesthesia Starts and Why Memories Get Fuzzy
Interviewer: And at what point do people start to I guess . . . This is a strange question, but when do they stop remembering? Is it when they're in the operating room, or is it before they get wheeled back?
Dr. Smith: That's such a great question. So for patients who are a little bit more nervous, which can definitely happen on the day of surgery, often you'll get some medication in your IV before you even leave that preoperative area. And if that's the case, then your ride back to the operating room is going to be a little bit fuzzy. Everything kind of from the time that you're leaving that room is going to be foggy when you're remembering.
Even with that in mind, for our patients who really want to remember the ride all the way back and remember what the operating room looks like, a lot of the medications that our anesthesiologists use, the doctors that put you off to sleep and wake you up again, will actually cause this thing called retrograde amnesia, which is where you forget things that have happened before you received the medication.
So even when you don't get any medication until you're in the operating room, sometimes you're still not going to remember the ride to the operating room or actually going off to sleep. It's a little bit different for every person.
Interviewer: And when it comes to anesthesia, when we're doing an operation like this, what kind of anesthesia is typically done?
Dr. Smith: So the vast majority of sinus surgery happens under a general anesthetic, which means that you're going totally right off to sleep in the operating room with a breathing tube, and then we breathe for you and keep you comfortable while you're asleep.
How Is Endoscopic Sinus Surgery Performed?
Interviewer: All right. So now let's start to actually get into the surgery itself. Is there anything that you and your team do to kind of make sure that . . . I don't know how else to say this, but that the nose is ready for this, the sinus is ready for this surgery?
Dr. Smith: I love that. Most of our prep happens before the day of surgery, making sure that we have an updated CAT scan and that we have a really excellent understanding of the disease.
But the one thing that almost everyone does before we start the operation is we actually put some pieces of cotton into your nose that have adrenaline or epinephrine on them. And this helps to decongest all the tissues in the nose to get it to be much less swollen. That way, we can see much easier during the operation, and the nose will actually bleed less. So that's one of the typical prep things that we do in the operating room.
Interviewer: So when you are operating on the sinus... and that's the cavity behind the nose, right?
Dr. Smith: Mm-hmm. Sinuses are a bit of a complicated structure. One of the ways that I like to describe it is to imagine they're a little bit like a honeycomb. So it's a space with almost an outer shell and then a bunch of little partitions inside of it.
And the usual goal is to take down those partitions so that we have a very open cavity into each of the sinuses so that they can drain properly, and also so that medication can get in after surgery.
Opening the Sinuses While Protecting the Eyes and Brain
Interviewer: Understood. And I guess how are you looking inside of there if it's that complicated honeycomb-type structure? Is it a tube? Is it an endoscope? Are you opening things up?
Dr. Smith: It's an endoscope and opening things up. So nowadays, almost all sinus surgery is done using an endoscope. And the ones we use are usually about four millimeters in diameter, which sounds big when you're putting it into a nose, but it's actually a really small camera. So it's great.
And then in this honeycomb-type analogy that we're going to use, we basically need to take down the different partitions in layers. As we take down the first layer, we're going to start to see the second layer and then the third layer. And so we're uncovering things as we go to get deeper into the sinuses and get them open.
Interviewer: Understood. I guess, are you checking for anything while you're cutting things out, or are you just trying to make some space?
Dr. Smith: Oh my gosh. So many things. The main goal of the surgery is to get the passages into the sinuses open. There are kind of four sets of sinuses on each side: your maxillary sinus, which is your cheek sinus; your ethmoid sinuses, which run along the eyes; your sphenoid sinus, which is very deep in the nose, almost between your ears; and then your forehead sinus, which is called the frontal sinus. And each of them has its own drainage path into the nose, into the nasal cavity itself, which is what we breathe through.
The goal of surgery is to make sure we find each of those openings and that we open them up nice and widely. And so, as we're going, we're looking for the natural opening of the sinus so that we can open it up into a more functional size. We're cleaning out polyps and inflammation, or blockages, as we come across them.
And then while we're doing that, we also need to make sure that we keep the eye and the brain safe, because the sides of the nose are basically the walls between the eye and the nose, and then the roof of the nose is the wall between the brain and the nose. And so, as we're trucking along, getting things open, we want to make sure we keep those structures safe at the same time.
Interviewer: And how do you do that?
Dr. Smith: A couple of ways. One is that we use our anatomy knowledge. There are a few preserved structures in 99.9% of patients, and that makes it easy to kind of move from one known landmark to the next.
And then we also have this very cool instrument called an image guidance machine. What it does is it actually takes CT scans that patients have had, and then we put those scans into the computer, and it will essentially build a GPS navigation system for the nose while we're doing the operation. That helps to confirm where we are in the surgery, and it also helps to keep us safe and reduce the chance of having any serious complications.
Interviewer: I understand that you have a camera tube that's going in there, you've got this imaging going on, etc., but what are you using to cut things? How are you actually making those incisions and things inside the person's nose? Are you just kind of roto-rootering someone's sinus?
Dr. Smith: That's such a great question. It's one that I get all of the time. We have an instrument called a micro-debrider, or micro-debrider, depending on where you're from, and it is basically a vacuum that has a little rotating blade on the end, kind of like a lawnmower.
What it does is it pulls the tissues we're trying to remove into the opening of the vacuum, and then it cuts them up into little pieces. And so that helps us remove most of the tissues that we're coming across, and a lot of people will likely describe that as having their nose roto-rootered out.
Interviewer: So you are roto-rootering it, but it's a much more delicate type of tool.
Dr. Smith: It's a very controlled roto-rootering, yes.
Interviewer: Okay. How long can someone expect to be under anesthesia during this type of procedure? How long are they going to be having all of this done?
Dr. Smith: That depends a little bit on how much sinus disease a patient has. Often, the surgery is tailored so that we're focusing on the sinuses that are actually problematic and leaving the healthy ones alone.
So someone who's having a less invasive surgery might only be under for a half hour, 45 minutes, and someone who needs to have all of the sinuses opened widely, particularly if they have polyps or bad inflammation, their surgery could last between 3 and 4 hours. So it can be quite variable.
How Surgeons Control Bleeding During and After Surgery
Interviewer: So let's start moving on to as you are kind of wrapping up in the OR. How do you keep the bleeding under control, especially if you're kind of taking down some structures to help free up the space in the sinus?
Dr. Smith: So that cotton with adrenaline or epinephrine on it is one of the main ways that we manage bleeding in the operating room. And we'll pack those into the nose, and then they essentially hold pressure on that space while the body forms a clot. That's one of the main ways that we control that bleeding.
Then we want to make sure that that space doesn't start bleeding again at the end of surgery, and so it's very common nowadays for us to place some sort of dissolvable packing into the sinus cavity at the end of surgery that essentially melts away with saltwater rinses over the course of the next week or so. And that's really helpful to decrease the oozing and bleeding that patients have after surgery.
The other thing that patients will often end up with as a part of their surgery is silicone stents inside of the nose that help to hold everything in place, that help to hold everything open, and often will make it easier for patients to do their saltwater rinses. And those are usually taken out about a week or so after surgery in the office.
Interviewer: I do want to ask, isn't that a lot of stuff up in a person's nose? I mean, if they come in feeling stuffy, aren't you stuffing more stuff up there?
Dr. Smith: It's actually pretty impressive. Patients with particularly crooked noses or who have bad polyps will actually tell me immediately when they wake up that they can breathe better after surgery.
Interviewer: Really?
Dr. Smith: But often in that recovery phase, it is going to feel like you have a bad cold. You are going to feel stuffy and congested, particularly for those first few days.
Recovering After Endoscopic Sinus Surgery
Interviewer: And so they're all packed up. They've been wheeled to the recovery room. How long until a patient usually wakes up?
Dr. Smith: So it usually takes somewhere between 15 and 30 minutes, depending on the type of anesthesia and the different patient factors or variables, for someone to be awake enough in the recovery room that they're actually making new memories or remembering what's happening.
But in between that time, there's this fun twilight period where people are really high as a kite, as I like to say. They don't remember much of what's going on, and they're always very entertaining. Yes, that's usually our wake-up.
Interviewer: Okay. And for someone who's maybe not experienced a surgery before, what happens in that discharge room? I mean, can family come back? Are they expected to remember instructions? What happens between them, starting to wake up feeling a little high, and getting home?
Dr. Smith: So when you're waking up, you will get to a point where you start to realize that you're awake, and you're like, "Oh, okay, my surgery is over. I'm feeling pretty good. This wonderful post-op nurse is taking great care of me and making sure that my pain is well-controlled, and I'm not nauseated. I'm feeling great."
Once you get to that point, that's when we usually say, "Okay, now is a good time for your family to come in." And then we'll start to go over your post-op instructions with you. We want to make sure that you have someone with you because you're not going to remember everything that we say. We also make sure everything is written down for you as well so that you have something to refer back to later.
What to Expect During the First Week of Healing
So you get your ride home. And then I tell patients they usually are not going to like me very much for the first couple of days after surgery, and that's because they are going to usually feel like they have a terrible cold.
Like we know, when you have a bad cold, you're stuffy, you're congested, your face feels full. Usually, you're not sleeping great. Your food doesn't taste awesome. And so, for those first couple of days, as your nose is recovering, most of my patients don't like me very much.
And then typically, you're going to start to get to Day 4, 5, 6 after surgery, and usually, there, people are starting to feel better. They're taking less pain medication. Even things like Tylenol and Advil tend to be adequate for most sinus surgeries, but you'll be taking less of them at that point.
You'll really start to feel like you want to start doing activities, cleaning your house, taking advantage of this time that you have off from work, but you're going to find that your energy is still very low. So you're going to start a task and then be like, "Ugh, I am too tired to do that. I need to go back to bed."
Most patients come to see us between 7 and 10 days after their surgery in the office so that we can take out those stents that I mentioned earlier, and also vacuum out any of that dissolvable packing that is still inside the sinus cavity.
And typically, on that day in the office, you're going to be feeling about 80%, 85% of normal when you leave your visit. So people usually feel pretty good that day.
Post-Operative Care That Helps You Heal Faster
Interviewer: And during that, I guess, first week of healing, before you get everything removed, is there anything that they or a caregiver should be doing to keep pain under control, minimizing bleeding, anything else to kind of make sure they have a good recovery?
Dr. Smith: Yeah, I would say there are three really important things to do in your recovery to make sure things go well. And number one is to make sure that you're taking regularly scheduled over-the-counter pain medications, like Tylenol and Advil. Those really help to reduce any narcotic requirements that patients have for pain in the time that they're recovering from surgery. So I think that's super important.
The second thing is, I do actually want you to take it easy when you're recovering from surgery, which means lazing about, not being super helpful at home. Still getting up, moving around, taking care of yourself, but this is not the right time to weed your garden, or start a home reno, or something like that.
And on that note, we do want patients to avoid heavy lifting, which means weights between 10 and 20 pounds, for that first week after surgery, pretty strictly, because that lifting can increase your blood pressure and actually increase the risk that you get a nosebleed after surgery. So we do want you to take it easy.
And then the last and probably the most important thing to make sure that the healing from your surgery goes well is that you need to be doing saltwater rinses of your nose or high-volume saline irrigations of your nose. Things like a NeilMed Sinus Rinse tend to be a very common example of that, or the neti pot.
I tell my patients that they need to be doing them three to four times a day minimum, and they have to use the whole bottle each time. And that helps to keep the sinuses clean. It helps to keep all the stuff that's building up in the nose moving, so that the nose can heal properly.
Warning Signs After Sinus Surgery You Should Not Ignore
Interviewer: During this aftercare time, that first week or so afterwards, when you're taking it easy, are there any, I guess, side effects or things that people can expect that might be a little concerning? I've heard that some people experience a bit of bleeding and a bit of congestion. What are some of the signs they should probably get back in, or call someone, or get something fixed that probably needs to be fixed sooner rather than later?
Dr. Smith: Absolutely. I would say that two things that we're being the most watchful for in that first week after surgery are either abnormal bleeding or signs of an infection.
So normally, after sinus surgery, your nose is going to drip blood. And I tell patients that if their nose is going "drip, drip, wipe, drip, drip, wipe," like a bit of a leaky faucet, that's okay.
The other metric that we'll use is a gauze under your nose to catch those drips. And if that gauze is getting soaked or full in less than half an hour, then that's a sign you're having more oozing than we would typically expect, and we would want you to call someone.
I also tell patients that if their nose is gushing, that's not normal. That's something we do want to know about. And you can usually call the hospital to talk to an on-call ear, nose, and throat doctor. Or if you're concerned, just come on in so that we can check you out.
When it comes to infection, the main things that we're looking for are fevers, worsening pain, or foul-smelling discharge coming out of the nose. Things that are really highlighter green, highlighter yellow coming out. And those typically will develop a little later in your recovery, around Day 6, 7, 8, often around the time that you're starting to come into the office, and we'll catch them when we're cleaning out the inside of the nose.
But either a nosebleed after surgery or a sinus infection after surgery happens in about 5% of patients who are having sinus surgery.
In terms of other things to expect, that congestion is very, very normal. You're going to feel like you have a bad cold. You're going to feel like you can't breathe through your nose. A lot of patients tell me they have regrets for those first few days, but it is going to get better with time.
The last two things that I wanted to mention in terms of complications to look out for or when to call are what we as the surgeons will call the dreaded complications of sinus surgery. And those are signs of damage to either the bone between the eye and the nose, or the brain and the nose. And the way that those problems can present is with swelling around the eye, bruising around the eye, and changes in vision. If you have any of those things, you should reach out to your surgeon right away or go to the emergency room.
And then similarly, if patients are having a clear fluid drainage out of their nose that's very drippy like a leaky faucet, or a really salty taste going down the back of their throat, sometimes that can be a sign of damage to the bone between the brain and the nose, like a brain fluid leak.
And so, if you're unsure, again, it's just good to reach out to your surgeon and team because we can help you navigate what is just all the normal drainage coming out of your nose versus something that's more concerning.
But particularly if you have symptoms like that, with a very bad headache that isn't improving with Tylenol and Advil, or you feel a little, I'm going to say, hard to focus, not well in a way that doesn't feel like what you have when you have a cold, those are things that are worth checking up on.
Again, it's very rare to have either of those complications, but they're things that we don't want to miss. And so I really encourage my patients, if they're at all unsure, to just reach out to the team because we see this all the time. We do lots of sinus surgeries every week, and we can help patients navigate that, but we really don't want to miss someone having those complications if they're happening.
Sinus Surgery Is Often Worth the Anxiety
Interviewer: Now, for someone who maybe has that surgery on the calendar and they're still feeling a little bit nervous, what do you say to those types of patients, and what can they expect once they're finally healed and done with the procedure?
Dr. Smith: I tell my patients, even on the day of surgery, if they're not nervous, they have to tell me what they took before they came in. Being nervous before surgery is so normal. When I had my surgery, I was so nervous, they had to premed me in the holding area. I was a terrible patient. So I think nerves around surgery are so normal and something we also expect to help you manage. That's probably the first thing I would say.
And what I would say is that sinus surgery is actually really helpful for patients. It provides significant relief of symptoms in terms of breathing through their nose, changes in the sense of smell, drainage coming out of the nose or going down the back of the nose, and even things like pressure and fullness in the face.
For patients who are having recurring sinus infections, it can decrease the amount of infections they get by about 50% per year, which is great for anyone who's having lots of sinus infections.
And one of my favorite stats that I like to tell patients is we can take you from a state where every single day you feel sick, you feel unwell, and with good sinus surgery and then with good maintenance therapy afterwards, I can get you feeling like someone in the general population who doesn't have sinus disease, which I think is just so impressive with the type of treatment that we have to offer.
Even though it's scary, I think it's very, very worth it. Nothing in medicine is 100%. Sinus surgery is pretty close. The vast majority of patients who are good candidates for this procedure and who then have this procedure have really excellent outcomes.