Chadwick N. Ahn, M. D. Ronald Shashy, M. D. Endoscopic Sinus Surgery



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Chadwick N. Ahn, M.D.

Ronald Shashy, M.D.

Endoscopic Sinus Surgery

What follows is a discussion of the indications, techniques, and complications associated with Functional Endoscopic Sinus Surgery. This information should be used to help you in making a decision about having surgery as well as providing you with a reference after surgery. It is NOT intended to replace the advice and recommendations of your physician. You are strongly encouraged to ask questions whenever something is not clear to you or you seem to be developing a problem. You will be given emergency contact numbers after surgery and you can always call the office at 502-226-6494.



Background and Theoretical Considerations

Endoscopic sinus surgery is a relatively new surgical technique that has revolutionized the management of chronic sinus disease. The technique was first developed in Austria and came to the United States during the 1980s. It has undergone several significant refinements and modifications over the years, but the basic principal has remained the same: the use of small, precise instruments viewed through a nasal telescope/endoscope to selectively remove diseased tissue from the sinuses, leaving normal tissue undisturbed. Each operation can be “tailor-made” to the individual and their specific problems.

Chronic Sinusitis has become a significant health concern in the United States and is one of the top three chronic illnesses afflicting millions of people each year. Hundreds of millions of dollars are spent each year treating this disease. The economic impact from missed work and decreased productivity is staggering.

People with chronic sinusitis suffer from a wide variety of symptoms. Some of the more common include: headache and facial pain, recurrent acute sinus infections, obstructed breathing, nasal congestion, nasal drainage, chronic cough, decreased smell, throat clearing, and ear pressure. The underlying abnormality in almost all cases can be traced back to inadequate drainage of the sinuses. This sets the stage for repeated infections or long-standing infections that respond poorly, if at all, to the usual sinus medications (antibiotics, steroids, etc.). Some people find that medications help, but once they are discontinued, symptoms promptly return. People with chronic sinusitis often have co-existing anatomic abnormalities that complicate matters. These can include septal deviation, concha bullosa, turbinate hypertrophy, and nasal polyps. The diagnosis of chronic sinusitis is confirmed in individuals who fail to respond to medical management by obtaining a CT scan of the sinuses. These scans can clearly show the areas of blockage and the anatomic abnormalities that often accompany them.

Endoscopic Sinus Surgery attempts to correct these problems of inadequate drainage by selectively removing tissue that contributes to the obstruction. It creates larger, easier to drain sinus cavities where there once were small, easily obstructed ones. This is done using small instruments introduced through the nose (no incisions) under the guidance of a telescope/endoscope. In this manner, normal tissue can be preserved, and only diseased tissue need be removed. Since no two sinuses are alike, each surgery is custom made for that particular individual and their specific problems and anatomy. Sometimes complimentary procedures such as septoplasty and turbinate reductions are performed along with the sinus surgery.

Sinus Surgery Details

Endoscopic sinus surgery is an outpatient surgical procedure that rarely requires a stay in the hospital. On average, the surgery lasts about 2 hours. More complex cases requiring the correction of multiple problems may take longer. The surgery is performed under general anesthesia with the patient completely asleep. The entire surgery is done endoscopically using high definition (HD) video and monitors. Image guidance techniques are utilized – this is modern technology that uses a sophisticated computer to track individual instruments as they pass into and out of the sinus cavities, giving the surgeon immediate feedback and assistance with navigation through complicated areas and anatomy. The computer will load the pre-operative CT scan and display three unique views for the surgeon to view – this is simply a tool that gives the surgeon more information. After surgery, the patient will be observed in the outpatient surgery recovery area for 1-2 hours and then allowed to go home with a friend or family member. I generally see patients back in the office one week after surgery. Medications will be prescribed to prevent infection, to relieve pain, and to moisturize the sinus cavities (saline nasal sprays).



Post-operative visits

Although the surgery itself is the most important FIRST step in treating your sinus problems, I cannot over-emphasize the importance of the post-operative care. Long term success is greatly influenced by the frequent and effective care administered in the early post-op period. I generally see patients back in one week, and then every 7-10 days after the first visit for an additional 2-4 visits. If conflicts arise with keeping your scheduled appointment, please call and we will be glad to reschedule. Please do not skip the appointment altogether. These post-op appointments are used to “debride” or clean the newly created sinus cavities, assess the healing process, and to make any necessary adjustments in medications. After the first few visits, these “cleaning sessions” will become very routine to you. These frequent visits also present a good opportunity to discuss any problems you might be experiencing.



Packing

In general, I do not use “packing” during sinus surgery. In the past, surgeons would use packing gauze and splints that gave this surgery a bad name/reputation. Modern endoscopic techniques give us the ability to perform surgery without the need for obstructive packing. I do place “spacers” in the ethmoid cavities – these spacers are simply a soft, cotton sponge that are placed within a non-latex, rubber sheath (the rubber makes removal at the first post-op visit easy and painless). The spacers do not interfere with breathing. Occasionally a dissolvable foam will be placed instead of the spacers. Septal splints are rarely used. My goal is to make the post-operative course as easy as possible for each patient, and I find that not using packing helps achieve that goal.



Post-operative pain

Sinus surgery is generally a very well tolerated procedure with mild to moderate discomfort being experienced by most. Obviously there will be patient to patient variability depending on several factors including extent of surgery, extent of disease, and patient’s individual response to pain. Prescription strength pain medications will be prescribed for use in the early post-operative period. If facial pain and headache were a common symptom of your sinus disease before surgery, it may take several weeks before you notice significant improvement. This is mostly due to the swelling that accompanies surgery.



Medications

In addition to pain medications, several other medications may be prescribed. Some of these may be familiar – you may have used them before your surgery. Some medications will be new. Antibiotics are routinely used after surgery to eradicate infection and to assist in the healing process. Saline nasal sprays are to be used frequently after surgery to help keep the nasal and sinus cavities moist. This moisture helps to promote healing. Medications to combat nausea that sometimes accompanies the use of general anesthesia are often given as needed to those individuals with a history of the problem. If you were using nasal steroids before surgery, it is ok to restart them a couple of days after the procedure. Patients are encouraged to begin taking all of their routine medications as soon as possible. As always, it is important to take all medications exactly as prescribed (unless noted by me) and to report any unusual reactions to the doctor immediately.



Irrigations

At your first post-operative visit, you will be instructed in the technique of “sinus irrigations”. This is different from the saline nasal spray that you will begin immediately after surgery. You may or may not have had past experience with irrigations. This method of delivering larger volumes of fluid to the sinus cavities further helps to wash away debris and hasten the healing process. The more that can be cleaned through the use of irrigation means the less that must be removed in the “cleaning sessions”. As such, this is a very important part of the post-operative care, albeit one that takes a little getting used to. Soon after surgery you will be asked to irrigate 2 or 3 times a day. The frequency of irrigations will decrease as time goes on and the healing process progresses.



Problems and Complications

In general, endoscopic sinus surgery is a safe procedure with an extremely low rate of serious complications. I have personally performed this procedure successfully in hundreds of patients. To date, no one has experienced a serious or life threatening complication. Complications following sinus surgery are divided into two broad categories: major and minor. The major ones are more serious, but fortunately, are MUCH LESS common (and even rare).





Major Complications:

  1. Orbital (eye) injury

As you might recall from the review of your CT scan, the sinus cavities are in very close proximity to the eyes. Inadvertent injury to the eye muscles, eyeball, and optic nerve has occurred in this type of surgery. I have never had this complication in one of my patients. Newer instrumentation and improved visualization along with the image guidance surgery all serve to diminish the risk of this serious complication.

  1. Brain injury

Also in close proximity to the “roof” of the sinus cavity is the base of the skull (on which the brain rests). Violation of the “roof” structures can result in leakage of spinal fluid (a.k.a. CSF), meningitis, bleeding around the brain, or direct injury to the brain tissues.

  1. Hemorrhage

Minor bleeding is to be anticipated. The spacers I place in the nose assists with keeping this bleeding to a minimum. Most patients have bleeding for 24 hours after the surgery. It is good to sleep with the head elevated for the first few nights to keep the oozing coming out of the front of the nose instead of down the back of the nose and throat. Major bleeding that occurs after surgery may require packing, cauterization, or potentially a trip back to the operating room for control.

Minor Complications

  1. Excessive tearing - epiphora

Swelling that accompanies this type of surgery sometimes partially blocks the tube (nasolacrimal duct) that drains tears from your eyes to the inside of your nose. Rarely, the tube itself may be injured during the course of the operation. Almost all of these problems resolve spontaneously without the need for additional treatment.

  1. Loss of Smell – anosmia/hyposmia

The smell receptors are located very high along the roof of the nasal cavity in an area that is easily blocked by swelling. We have all experienced temporary loss of smell associated with a severe cold or the flu. The same thing happens after nasal and sinus surgery. Your sense of smell should return to normal in a couple of weeks. Those who had lost their sense of smell before surgery (usually due to anatomic problems or nasal polyps) may experience a gradual return over a period of several months. Rarely, the sense of smell may remain diminished.

  1. Foul odor in the nose

This is due to the accumulation of crusting, old blood and mucus in the newly created sinus cavities. This will improve as the crusts and blood are removed and the healing progresses. Foul odor may also be due to infection that might require antibiotics for complete resolution.

  1. Abnormal scar formation

This surgery is designed to create larger, more functional drainage pathways out of the sinuses into the nose. Rarely these openings will close down as they heal. A minor amount of narrowing is anticipated and acceptable. Significant narrowing can jeopardize the long term success of the operation. Minor revision work on these areas of narrowing can often be accomplished in the office. It is impossible to predict who might develop this type of problem, but failure to abide by meticulous postoperative cleaning is a known contributing factor.

  1. Recurrent or persistent sinus problems

Even successful sinus surgery does not guarantee that you will never develop another sinus infection. In fact, most of you will, but these infections will be much less frequent, much less symptomatic, and much easier to treat. Some symptoms for which surgery was performed may persist after your surgery. You must look at the success or failure of surgery for sinus disease in a “big picture” approach. The vast majority of properly selected patients will experience significant improvement in most, if not all, of their sinus symptoms.

  1. Septal perforation

In the event that a septoplasty has to be performed during the surgery, there is a small risk of a perforation/hole developing in the post-operative period. I perform an endoscopic septoplasty, which theoretically lowers the risk of perforation. Common complaints stemming from a perforation include a nasal “whistle” and nasal obstruction from turbulent airflow. External deformity (collapse of the nose) is an extremely rare potential complication.

I hope this information has been helpful to you and encourage you to ask questions if something is not clear or you feel you are developing a problem after your surgery. Please don’t hesitate to call me anytime.



Chadwick N. Ahn, M.D.

Ronald Shashy, M.D.


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