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This section is an analysis of those situations where sinus surgery doesn't achieve the desired goal. I also go over those measures that I take to reduce failure rates and how to deal with failures should they occur.
Many people have had some type of nasal procedure and didn't get the benefits that they had hoped for. There are some very specific reasons for this in most cases, and there are measures that can be taken to be reduce the chances of this happening. That said, it would be wrong to suggest that all sinus problems are "fixable" or that everyone ends up problem free after surgery.
In general, the results from modern endoscopic sinus surgery are very good. The success rates are near the 90% range, but some problems are more predictably correctable than others. Also, when you speak to friends who have heard "stories", do be aware that people who continue having problems are more likely to tell their story than those who had a simple procedure and went on their way trouble free.
Here is a list of the common reasons for the failures of sinus and nasal surgery and what I do to minimize the chances of these things happening to my patients.
Prior to about 1991, there was basically no endoscopic sinus surgery performed. Between about 1991 and 1994 the field was rapidly developing and very few surgeons had good experience using the tools and techniques that we now take for granted. The only sinuses that were commonly operated on were the maxillary sinuses. Problems in the ethmoids, frontals, and sphenoids were very difficult to treat and to diagnose.
The common non-endoscopic operation was to perform a septoplasty if needed, place naso-antral windows, and possible remove a portion of the inferior turbinate (sometimes too much). If such patients had disease in the ethmoids, frontals, or sphenoids, they would usually only get a partial improvement. This is a very common scenario. Before endoscopic techniques it was dangerous to get into these sinuses and it required incisions on the face that left scars. Its understandable that these commonly infected and involved areas were left alone.
- Today almost all patients will have a CT scan to identify all of the problem areas, and in the right hands, all of these areas can be safely addressed with relatively minor procedures.
This statement isn't quite what it seems; let me explain. A common scenario of failure that I see is in the patient who came in and presents with the common complaint of congestion and trouble breathing, perhaps even sinus pain. The doctor looks in the patients nose and discovers a significant nasal septal deviation. He thinks to himself, wow, that crooked septum sure needs to be fixed; and he is correct. The missed opportunity comes when other problems that can exist along with a deviated septum are not explored. Chronic sinusitis is very common, and probably more common in people with severe septal deviations.
So the doctor fixed the septal deviations and the patient may breath a bit better, but the problems aren't entirely corrected. It turns out that this patient also had a significant chronic sinusitis that was a contributing problem, but perhaps didn't have characteristic symptoms. If the doctor had done a CT scan before surgery, then these unexpected issues would have been revealed. In fact, in this patient, the chronic sinusitis may have been clearable with proper medicines and avoided surgery all together. This is the worst case scenario, having a procedure that isn't helpful for a problem that might clear with medicine.
- One can avoid this problem by ordering a pre-op CT scan on patients who are having almost any type of nasal surgery. Even when there is no chronic sinusitis suggested on the scan, it helps me plan the septoplasty and possibly the turbinate reduction. I am amazed at how often I discover an unexpected chronic sinusitis, concha bullosa, or other issue in a patient who you would think only needs a septoplasty. Considering all of the expenses associated with surgery, a $350 dollar CT scan, that is generally covered by insurance, is a dollar very well spent in my opinion.
This happens to all sinus doctors from time to time. A common scenario is that a patient has the story of chronic sinusitis. A long regimen of antibiotics is given, a CT scan is obtained at the end and it shows certain sinuses that have become difficult to clear. A minor procedure is performed to open those particularly difficult sinuses;, the other sinuses are left undisturbed, as they should be. After surgery, things are better but the patient develops infections that once again are hard to clear. Eventually another CT scan is obtained, and it shows that some of the sinuses that were not operated on are the ones contributing to the difficult infections.
This scenario is not that uncommon. The initial premise that modern sinus surgery tries to follow is that one should not disturb structures that are not causing a problem. This eems reasonable enough, but to really know if removing a structure will help sinus problems is not always that easy. In the patient in the scenario above, it was assumed that the CT revealed a chronic source of infection and it was at the root of recurrences and flare-ups. As the story progressed after surgery, it might prove that they had multiple areas that caused problems, but that some were cooled down at the time of the CT scan.
Despite this shortcoming in the logic of our modern techniques, there is little that can be done to avoid this pitfall. I will typically do a good examination of the areas that I am not planning on operating just to be sure that they look good through the scope as well as on the CT scan. The other way to help get information about such areas would be to do a CT scan at times when the patient is more symptomatic. The problem here is that one would probably operate on areas that could be cleared with medicine.
- There is no absolute solution for this problem. The number of patients that fall into this category can be minimized by using good judgment and by asking the patient if they would prefer the surgery to entail more or less work, knowing that there are unclear pro's and con's of each option. The positive of doing a bit more is that there will be less likelihood that a seemingly normal sinus will become obstructed later on and less likelihood of needing a second "tune up" operation. The negative is that it is more surgery, potentially on structures that would be OK if left alone, and a slightly increase in the risk of bleeding or blockages developing during the healing phase.
When a patient needs a second operation because of this sequence of events, I think it is wise to change the philosophy. The goal of a first (hopefully only) sinus procedure is to do the least work that will likely relieve the problem; this serves most patients very well. The goal of the second operation is to be pretty sure that there won't be a third operation. With this philosophy, I usually open any sinus that is a possible suspect where it is safe and simple to. This varies with patient's history and anatomy.
Some patients with chronic sinusitis have a problem called Allergic Fungal Sinusitis, (AFS). This is one group of patients that is often not "cured" with sinus surgery. This problem amounts to a reaction that some people have to mold spores that are in the air. It is not actually an allergic reaction. People with this problem typically have nasal polyps and have a thick material filling one or more sinuses. Some controversial theories suggest that many patients who don't have polyps or obvious fungal material may have the same reaction but to a lesser degree.
People with allergic fungal sinusitis are more prone to re-grow polyps and have swelling even if all of the problem sinuses are open and well treated. In these cases, surgery is very helpful and is one of the only hopes of having less trouble, but in some patients the process continues despite surgery and medicines.
- For some patients there is no easy solution to this problem. Surgery almost always makes symptoms less and makes AFS flare ups easier to treat. Oral steroids like Prednisone are dramatically helpful, but they have side effects that make them unsuitable for frequent or prolonged use.
Rinsing with anti-fungal medicines has been shown to help reduce recurrences. These rinses are not likely to be helpful unless the sinuses are surgically opened.
Careful follow up in patients with AFS, use of steroids where appropriate, and the use of topical anti-fungal agents can help reduce recurrences in patients with AFS.
Some patients with AFS may end up needing occasional removal of polyps or sometimes re-operation with more extensive procedures to control the disease.
Some polyps are from causes unclear. When that is the case, sometimes they can be removed and never come back, other times, no matter what is done, the polyps return. In patients with polyps, it may be necessary to go back and clean out any re growth to provide drainage and nasal airway.
When this becomes necessary, the return trips to the OR can often be spread out by many years and the return trips are usually minor procedures. Steroid injections into developing polyps can slow or reverse their growth as can teroid sprays. The goal is to keep things reasonably open and comfortable, and to spread out any additional surgical polyp removals as far as is possible.
There are times when the perfect operation is performed on the perfect patient, and things don't heal up as expected. There are certain problems with the post operative healing that are well known. Some people might refer to this as "scar tissue" forming. The problem is actually that mucous membranes healed over places that we wanted to stay open or healed two adjacent structures together.
Poor healing is most likely in patients with active inflammation at the time of surgery or post operatively. Some problems are more inflammatory than others and this is fairly easy to evaluate at the time of surgery. Poor healing can also happen more easily in patients with very small nasal dimensions.
- I think that the source of much poor healing is when post operative blood hardens in the cavities and provides sort-of a "bridge" for the mucous membranes to grow across. In the weeks after surgery, it is very helpful to examine the patient, and if there is evidence of retained blood, it is cleaned out. Cleaning post-operative cavities, when needed, is a critical step in some cases.
The healing of the middle turbinate outwards is a common example of a surgery site not healing as desired. Sometimes it is helpful to remove a portion of the middle turbinate to prevent this if it is suspected that this may happen. Often I use a dissolvable suture to try and prevent this. Sometimes this problem will need to be addressed in the post operative visits if it happens unexpectedly.
In my opinion, this can be the worst situation. Out of the many patients I deal with each year, about 2 or 3 will have this problem. It usually happens in people who have had a long standing bacterial infection in the maxillary sinuses or those with some type of immune problem like diabetes.
In such patients, after surgery, the sinuses may heal as expected, but puddles of apparent infection remain pooled in the bottom of the maxillary sinuses. Bacterial cultures are taken but for some reason, they frequently do not reveal the bacteria that is at the root of the problem. Perhaps bacterial are not really at the root of the problem, but it appears that they are. So multiple antibiotics are given, based on educated guessing, but the puddles persist. The most common symptom is post nasal drip and cough.
- This is a difficult problem, and usually a resolution can be achieved. In my practice, the next steps involve:
- Repeating cultures, because sometimes a responsible bacteria can be identified and treated with unexpected antibiotics
- Frequent clinic returns and instilling strong antibiotics directly into the sinus and cleaning out of the sinus. While it is never done, I think that if such patients were put to sleep every day for a couple of weeks, and their sinus was rinsed out aggressively and antibiotics place in the sinus, such patients would clear up. This is not practical, but in office visits 2 or 3 times a week for rinsing and antibiotics is sometimes possible to arrange.
- Using antibiotic rinses at home
- Considering placing a "window" at the bottom of the sinus. This lets the material drain by gravity some and allows antibiotic and or saline rinses to get into the sinus more completely
- Eventually one can "saucerize" the sinus, and this almost always improves the volume of infection and permits the infection to be better controlled. The negative is that it changes the natural anatomy fairly dramatically and many patients will get relief without taking this step.
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