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

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 preoperative 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 postoperative 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.
2. 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.
3. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.