Nasal/ Sinus Surgery:

Mark E. Reiber, M.D., F. A.C.S., F.A.A.O.A.

Recurrent sinus infections or chronic nasal blockage may not only be from allergy, but from structural problems in the nose requiring surgery. In some cases, you may be able to see a deviated septum or large polyp obstructing the passage, but in other cases, a thin endoscope will reveal enlarged turbinates or other abnormalities. Finally, a CAT scan provides a complete picture of all the nasal and sinus structures to assist with surgical planning.
The most common surgical procedures for the nose are:

Septoplasty
The nose is divided by a cartilage and bone wall called the septum. It can become crooked from birth, trauma, other nasal abnormalities, or just simply as “part of life”. A deviated septum makes you more susceptible to nosebleeds, impedes your use of nasal sprays, and makes access for surgery more difficult, but mainly it causes obstruction.

Obstruction is generally worse when lying down due to venous pooling of blood and congestion. Patients often try topical decongestants for relief but this leads to dependency and rebound congestion.

Septoplasty is an outpatient procedure, done through the nostrils, with no external incisions or bruising. Recovery is about a week, and tolerance and satisfaction are generally high. Complications are rare and include: need for revision, septal perforation, infection, bleeding, and numbness or sensory abnormalities of the face or teeth.

Turbinate Reductions:
Turbinates are shelf-like structures extending from the sides of the nose and covering the sinus openings and tear ducts. Each side has an inferior, middle, superior and sometimes supreme turbinates.

The inferior turbinates may be seen just inside the nose and are sometimes mistaken for a nasal mass. They warm and humidify the air coming into the nose. In allergy, they become large, pale, boggy, and watery. Various methods have been developed to reduce their size.

The middle turbinates cover the major openings of the sinuses. They are usually preserved during sinus surgery, but may be removed or trimmed. A concha bullosa cell is a naturally enlarged air cell in the center of the middle turbinate that can cause sinus blockage, headaches, and nasal obstruction.

Endoscopic Sinus Surgery:
Today, almost all sinus surgery is performed with endoscopes and small instruments through the nose. Newer techniques utilize “shavers” and balloon catheters to remove tissue and dilate sinus openings. The days of gauze packing have disappeared and most cases require only jelly like materials and other dissolvable materials following procedures. These advancements have made surgery less painful and shortened recovery times.

Surgery is necessary for irreversible, chronic infections, unresponsive to medications, structural problems, and a few other limited situations. The goal of most procedures is to open the sinus’ natural openings to re-establish drainage. After surgery, keeping the openings patent and limiting scarring is critical to long term success.

Maxillary sinus:
These are the large paired sinuses under the eyes. Pain from them is in the mid-face, below the eyes, and in the upper teeth. The sinus lining has small hairs on the surface directing mucus flow towards the top of the sinus and into the nose through a small opening. Surgery dilates this opening with either a balloon catheter or endoscopic instruments.

Ethmoid sinus: These are a labyrinth of honeycomb-like air cells along the middle wall of the eye. The bone has an egg-shell consistency that is easily broken and removed. The frontal sinus drains through the front cells and the sphenoid near the rear. Pain resulting from the ethmoid sinus is between the eyes. Balloon catheter techniques are not appropriate for ethmoids.

Frontal sinus:
Frontal sinuses can be massive, small or non-existent. They are paired in the forehead, above the eyes, which is where pain would be felt. Most headaches in this area are not the result of frontal sinus disease. This is the most inaccessible and difficult sinus for a surgeon to maintain. Balloon catheter techniques have shown promise, but numerous procedures have been designed to deal with this difficult sinus.

Sphenoid sinus:
These paired sinuses lie next to one another in the middle of the rear of the nose. Pain associated with these sinuses is behind the eyes or at the top of the head. Balloon catheter techniques are useful to dilate their openings or it can be done with traditional instrumentation.

2-27-08