Sinus411.org

The web site for people with sinus problems

What does sinus surgery involve?

How are the sinuses opened and the polyps removed?

There are a number of things accomplished during sinus surgery typically.  For patients with nasal polyps, the polyps that obstruct the nose and sinuses are removed.  For patients with sinus infections, the sinuses are opened, drained, irrigated, and cleaned out to help resolve the infections and reduce the chance of infections recurring.  Polyps and infections are the most common reasons for patients to undergo sinus surgery.  Other indications for surgery are less common and include treatment of mucoceles, cerebrospinal fluid leaks, tumors of the sinuses, epistaxis or nosebleeds, and others.

How are the sinuses opened and the polyps removed?

Sinus surgery is generally done under general anesthesia.  Sometimes a local anesthesia is used with intravenous drugs to provide sedation of the patient.  In either case, the procedure is similar.

During surgery, the surgeon uses a 4 mm fiber-optic and the scope to visualize the nose and the sinuses.  Small grasping, cutting, suction, and other instruments are used to remove polypoid tissue, inflamed sinus tissues, small bits of bone, and other tissue that needs to be removed.  The openings into the sinuses are enlarged where it is necessary.  If there is infection or debris or fungus within any of the sinuses, it is cleaned out of the sinuses using suction's, irritations, and other methods.  During the surgery, the delicate mucosal tissues lining the sinuses is left intact as much as possible, so the mucosa can reform, re-grow, and become healthy again as soon as possible.  This is called a mucosal sparing technique.

During the surgery, if there is evidence of infection in the sinuses, the surgeon will typically collect a specimen for culture.  The specimen is sent to the microbiology lab and in bacteria or fungus is cultured.  Once a particular species of bacteria is identified, it can be tested to identify which an emphatic or antibiotics is most susceptible to, so that the best and a bad choices can be made to help the patient heal in the post-operative period.

At the end of surgery, the surgeon makes a choice about whether to place any material to help with clotting and/or healing.  There are a number of absorbable packing materials that are designed to assist with wound healing and comfort in the postoperative period. In addition, there are several different non--- absorbable packing materials that are sometimes used as well.  Typically the decision about what material to use is made on a case-by-case basis by the surgeon.

What can I expect after surgery?

 After surgery, the patient is transferred to the recovery room.  The amount of time and recovery is quite variable.  It can be quite sure if the patient had a local anesthesia with sedation or it can take two to three or more hours after a longer surgery under General's anesthesia.  Patients often have some headache or facial discomfort after the surgery, but the recovery room staff can usually make any discomfort quite tolerable.  Many patients are discharged home the same day as surgery and follow up in our clinics several days after surgery.  The follow-up period can be as short as one day or sometimes as long as two weeks after surgery, depending upon the patient's particular disease and the operative findings.

What should I be aware of or lookout for after surgery?

Complications after sinus surgery are rare, but do occur in a very small number of patients.  If you have questions, you are encouraged to call the contact number is given to you after surgery.  This is typically are nurses station.  The nurses can answer many questions and can confer with the physician staff if necessary.

If you have a fever over 101.5°F within the first two weeks after surgery, you should call your physician's office and discuss it with the staff.  If you have a severe headache after surgery that does not prove with a typical pain medication, or if you have a headache associated with a fever, you should call your physician's office as well.  In the first few weeks after surgery, a fever associated with a severe headache could be a sign of meningitis, a serious infection of the brain.  Although this is very rare after sinus surgery, it can occur and should be taken very seriously.  Other symptoms of meningitis aside from headache and fever would be nausea, vomiting, stiff neck, sensitivity to light, agitation, excessive sleepiness, or significant behavior changes.  Although the symptoms could occur for instance with a severe by the viral syndrome (a cold virus), or with a need migraine headache, one needs to be aware of the small chance of meningitis.

Another rare complication after sinus surgery would be a spinal fluid leak.  This could arise from a small break in the thin skull bone between the brain and sinuses.  If this were to occur, usually the patient complains of clear fluid draining from one nostril or another, worse when bending over.  This clear fluid will drain and wet a pillow sometimes when the patient lies flat.  This clear fluid is much more excessive than one would expect with a cold and usually arises from only one side of the nose, unlike a cold.  When patients telephone with clear fluid draining for the nose, we often determine that it is due to salt water irrigation becoming trapped in the sinuses and later draining out when the patient turns his or her head.  We counsel patients to stop doing salt water irrigations for a while to determine if the drainage is due to the salt water.  It's clear drainage for the nose persists, the physician staff need to be notified immediately for evaluation and treatment, because a small leak can predispose a patient to meningitis, a serious infection of the brain.  If a small leak is found, it can usually be easily repaired.  Please read the section on meningitis above.

Eye complications after sinus surgery are rare, but can occur.  In about 1-2% of patients, there is a small amount of bruising near the inside corner of the eye.  If this occurs after the surgery while in the hospital, patients or let their caregivers be aware of this.  If it occurs at home, patient should call and notify their surgeon's office.

 Severe bruising, purple is discoloration, swelling, or other dramatic eye changes is not usual after sinus surgery.  If they occur, the surgeon's office should be notified.  Likewise, any  change in vision, double vision, blurred vision, darkening of vision, or loss of vision should be treated emergently.  The patient should call the surgeon or his staff and if they are unavailable, the patient should go to the emergency room.

Other complications after sinus surgery are rare and the patient concerned about a complication should discuss it with their surgeon and/or their staff.

What medications will I be taking after surgery?

After surgery, you will most likely be discharged with some pain medications, antibiotics, salt water sprays or rinses, and sometimes other medications.

Pain medications are helpful, particularly within the first several days.  Expect some discomfort after sinus surgery, but any one of several different types of pain medications ought to be able to relieve the discomfort to a great degree and help with sleep.  Typically, the pain or discomfort improves each day after sinus surgery.  If your pain is getting worse and worse every day, you should discuss this with your surgeons staff or with your surgeon.  Remember, pain medicine can cause constipation so consider taking a stool softener, eating high-fiber meals, brain and, etc., particularly if you expect you'll be on pain medicines for more than a couple of days.

Antibiotics are often (but not always) given to patients after sinus surgery.  If you have difficulties with your antibiotics (for instance a rash, itching, nausea, or other concerns), talk to your doctor's office.  Remember to take the antibiotics as prescribed.  If you are not sure, ask your doctor or pharmacist if the antibiotic can be taken with milk or food.

Some patients, particularly those patients with polyps, may be given a course of steroid pills to be taken after surgery.  Sometimes a steady dose of steroid pills are prescribed and sometimes a tapering dose of steroid pills are prescribed.  Steroid pills may help the sinuses heal and reduce the chances that polyps will start to form immediately after surgery.  If you have diabetes, ulcers, uncontrolled hypertension, a history of tuberculosis, problems with steroid pills,

Usually patients are recommended to use saline sprays or saline irrigations in order to keep the nasal cavity and sinuses moist and clean while the healing process occurs.  Surgeons do very considerably regarding postoperative saline sprays or irrigations.  Some surgeons recommend a saline spray that is delivered as a mist.  Other surgeons recommend saline irrigations using an irrigation bottle (for instance, the NeilMed Sinus Rinse System).  .   Many surgeons feel that keeping the nose moist is helpful to promote healing of the sinuses. It is critical that the sinus mucosa heal well and that the small hair cells or cilia in the nose and sinuses return to normal function.  If the cilia are not functioning properly, the mucus in the nose tends to stagnate, dry, become a crusted, and then become infected with bacteria.   Keeping the nose moist reduces the crusting and probably helps with healing and preventing infections. 

What happens in the first couple of office visits after sinus surgery?
After sinus surgery, patients typically returned to her three times in the first month.  During those office visits, nasal cavity is sprayed with a medication to decongestant or "open up" the nose.  This medication will also not the nasal cavity to a great degree.  During the first two or three visits, the surgeon will typically placed in the scope into the nose and gently suction out or remove blood, clots, mucous, and any extraneous bits of tissue or bone that might otherwise process.  This takes several minutes usually and can be uncomfortable for some patients.  Some patients elect to take one of their pain pills as they arrive to the clinic (if someone's available to drive them home), while others have no problems or discomfort.  If you are concerned about postoperative discomfort in the office, ask your surgeon whether or not you should take medications.

During these first two or three postoperative visits, the surgeon will be carefully assessing your nose and sinuses to be sure it is healing well, without signs of infection, early polyp growth, or other wound healing problems.  Occasionally medications, sprays, antibiotics need to be modified or added to optimize wound healing during this period of time.

How often will I need to be seen after sinus surgery?

Healing after sinus surgery is slow, and it's quite variable from patient to patient.  How often you need to be seen will be greatly dependent upon how weekly the surgical site heals.   Very minor surgery might heal within the first couple of weeks.  Surgery on all of the sinuses (4 sinuses on each side) might take six to nine weeks to heal and perhaps longer.   After the lining of the sinuses had healed, a small hair cells or cilia on the surface lining must begin to function properly for the nose and sinus to be healthy.   It is critical that the sinus mucosa heals well and that the small hair cells or cilia in the nose and sinuses return to normal function.  If the cilia are not functioning properly, the mucus in the nose tends to stagnate, dry, become a crusted, and then become infected with bacteria.  Therefore, usually patients are recommended to use saline sprays or saline irrigations in order to keep the nasal cavity and sinuses moist and clean while the healing process occurs.   At the University of Michigan, your surgeon will want to see you back intermittently during the first month or two in order to be sure that your sinuses are healing properly and best able to "take care of themselves".  Again, this usually takes several weeks.

If I have true bacterial infections, what are the chances that the infections will return after sinus surgery?

This is a very fair question, but one that is typically difficult to answer.   Every patient is different, so it's very difficult to make predictions for any individual patient, much less a prediction that we can publish on a webpage for “all-comers”.  Some authors have estimated that “the majority” of patients get “substantial improvement”.    Other medical publications cite percentages on the order of 80-90% of patients have “improvement”.   You’ll note the language used in these estimations (and similarly the language used by your own surgeon), again because its so hard to predict.   You may ask: why is it so hard to predict whether a patients infections will improve or not?

Well, there are many factors related to the patient that have great influence on the outcome after medical or surgical treatment of sinus disease.  A patient's age and other medical conditions may substantially affect how they will heal after sinus surgery.  For instance, patients with diabetes have more difficulties clearing infections.  Likewise, patient who spoke, and particularly those who continue to smoke, have more difficulties healing.  Patients with severe allergies, asthma, or nasal polyps have more difficulties clearing bacterial infections that occur simultaneously with these conditions.  Patients that are immunosuppressed because of other conditions, transplants, or medications will often have more problematic infections and difficulties clearing infections.  On top of the patient -- related factors, there are other factors such as the type of bacteria causing infection, whether that bacteria is resistant to antibiotics, whether the surgery was successful at cleaning out the infected debris from every nook and cranny, whether the patient heals well or not, whether the patient is able to tolerate the medical treatment needed after surgery, and the list goes on.  So, at best a surgeon can only estimate from his or her her own experience with patients sharing many (but not all usually)of the same characteristics as you.

As you discuss your surgery with your surgeon, you may get a sense whether he or she has considered these different factors and other factors as well.  If you are unsure whether your surgeon has considered these factors, you should feel free to ask if any of these factors will have an impact in your particular treatment.

If I have nasal polyps, what are the chances that the polyps will return after surgery?

Again, it is difficult to predict for any one patient if or when polyps will return.  However, most surgeons will recognize that patients with polyps scattered throughout the majority of their nasal cavity and sinuses will almost always have some degree of recurrence of their polyps.  In fact, patients with severe asthma and severe polyps almost always have a recurrence of their polyps over time. 

That being said, it is important to recognize that there are in number of medical treatments and "tricks" that will probably affect the rate at which polyps recur.  In addition, the medical and surgical literature would support the notion that a more thorough surgical clean out of the sinuses reduces the rate at which polyps recur and is probably an important factor for predicting how fast these piles recur.  With this in mind, many community ENT sinus surgeons, when faced with a patient to his head multiple sinus surgeries already, will refer these patients to a tertiary care center or a center of excellence nearby that has an surgeon with experience with "difficult sinus cases".

We evaluate a large number of patients with difficult to treat sinus conditions every year at the University of Michigan.  In fact, the typical patient who we operate on has had more than one sinus surgery in the past and frequently has had many previous sinus surgeries.  Because we see so many patients with difficult to treat sinus disease, we spent a great deal of time evaluating "what works" for these patients.  We have identified strategies to manage patients with difficult sinus infections and recurrent sinus polyps.  These strategies involve both medical management and also techniques to improve the surgical management of these patients.  The rhinologists at the University of Michigan network with other rhinology specialists in the United States and elsewhere, and we are able to focus our energies on providing state of the art evaluation, management and treatment of patients with these difficult problems.   We are confident that our “focus” and experience allow us to evaluate and treat you had your condition optimally.