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Nasal Septal

Modern Sinus Surgery

Sinus surgery has changed dramatically from that which was done in the early 90's and before. Two important changes are primarily responsible.
    1- A philosophy that chronic sinus problems can often reverse simply by improving the drainage pathways of the sinuses.

    2- The new equipment to perform this task with minimally invasive endoscopic techniques.
The great majority of modern sinus procedures are performed through nasal endoscopes. Prior to endoscopes, it was often necessary to make external incisions to access the sinuses. Unnatural drainage pathways were created and healthy tissue was injured or removed unnecessarily.

Using endoscopes, almost all surgical procedures are done through the nostrils without any external cuts. All of the sinuses can be safely examined and treated in this fashion. The natural drainage pathways are enhanced and attempts are made to remove only obstructing or chronically infected tissue, leaving the remaining structures undisturbed.

Exactly what is done in any one procedure is dictated by various factors, especially the findings of the CT scan and the nature of the symptoms.

Check-in and Anesthesia

The patient would arrive at the minor surgical center in the morning. After a brief check in, perhaps a bit of waiting, and a medical evaluation by the anesthesiologist, you are brought to the operating room. Most often, general anesthesia is used. Exactly what medicines are used during anesthesia depends on your age, health, the expected duration of the procedure, and the anesthesiologists judgment.

The Beginning of the Surgical Procedure

Once asleep, sterile sheets and towels are used to cover up everything except for the nose. Cotton patties with decongestant liquid are placed in specific locations in your nasal cavity. After waiting several minutes for the decongestant to take effect, the nasal endoscopes are brought into the field. The nasal passages are examined by passing the endoscope into the nooks and crannies of the nasal anatomy.

In most cases, the initial work is done under the middle turbinate. This structure is usually pushed towards the midline, but occasionally a portion needs to be removed to provide access to the sinuses or to create a wider drainage path or to allow better post operative cleaning and examination. The bone of the middle turbinate is often very thin, thinner than fingernail.

The area under the middle turbinate is called the middle meatus. Here is where most of the sinuses drain. The uncinate process is the first structure that is encountered. This small crescent of bone and membrane is the main "gutter" for these sinuses.

I know this analogy is a bit far fetched, but.....
People with sinus problems have "leaves in their gutters". It is impossible to really clean them out and keep them out, so when you remove the "gutter" (the uncinate process), then the rain can at least drain straight off of the roof. This opens up the drainage pathway to the maxillary sinus, anterior ethmoid sinuses and frontal recess.The uncinate process is partially removed in most endoscopic procedures. An example of a sinus surgery that does not include an uncinate resection would be if a patient only needed the sphenoid sinus (one of the far back sinuses) opened. In those cases where balloon sinuplasty is performed, the uncinate is not removed.

Once the uncinate has been removed, the surgeon can see the natural opening to the maxillary sinus and can see the anterior ethmoid sinuses using the endoscope. Each procedure is a bit different in that the surgeon will only operate on those areas that are proven or suspected to be a problem.

Endoscopic Surgery on the Maxillary Sinus

The maxillary sinus is included if it has been frequently or chronically infected or if it contains symptomatic cysts or polyps. Once the uncinate process is removed, the natural opening of the maxillary sinus is examined. The opening is enlarged by removing some of the fibrous wall that the natural opening is located in. A normal opening is about 5 millimeters in diameter. This size is usually enlarged to 1.5 or 2 centimeters. Care must be taken to ensure that the natural opening is contiguous with the surgical opening. Inadvertently creating two separate passages is thought to be a source of continued problems after this procedure.

If there is infected material in the sinus, it is usually rinsed out. Cysts and polyps are removed by using special instruments that can reach way around the corner and endoscopes that look at an angle. In some instances another opening is made at the bottom of the sinus to help provide access if it is necessary to remove cysts, polyps, or fungal material. This opening is similar to the older "windows" operation. When these windows are used to access the bottom of the sinus, they are often created in a way that encourages them to heal over after the procedure and return to their natural condition.

It is almost never necessary to make the incision under the lip anymore, except when dealing with some tumors.

The maxillary sinus is one of the sinuses that may be treatable with the new balloon sinuplasty tools. The indications for using this new instrument depend on the nature of the sinus problem and on several other complicated variables. Balloon sinuplasty has pros and cons as do any of our available techniques and instruments.

Endoscopic Surgery on the Anterior Ethmoid Sinuses

Between your eyes is a large group of sinuses that are shaped like a honeycomb. Multiple small sinuses, each the size of a pea or bean, fill the space between your eyes. When these multiple small sinuses become chronically infected and obstructed, they require removal.

Surgery on the ethmoid sinuses entails removing the paper thin walls that separate the honeycomb-like cavities. When an ethmoidectomy has been completed, instead of having, for example, 8 small ethmoid sinuses on each side, each the size of a pea, you end up having just one cavity the size of your thumb on each side.

Instead of these multiple small sinuses having to drain one past the next through small opening and passages, but now there is one cavity that can drain freely straight down. For patients with some abnormality of the mucous membranes, removing all of these walls reduces the total surface area of the mucous membrane, and this proves to be quite helpful.

Endoscopic Surgery of the Frontal Sinus

The frontal sinus can be a particularly difficult sinus to treat surgically. In the past, patients had large incisions on their brow, or in the hairline to access this sinus. Now, almost all frontal sinus surgery can be done endoscopically. Fortunately difficult frontal sinus problems are not present in most patients, but when they do occur, very specialized surgical techniques need to be employed. Not all sinus surgeons frequently perform endoscopic frontal sinus procedures. One example of an advanced frontal sinus procedure is the Modified Lothrop. Surgeons who perform this operation generally have the special skills to treat the difficult frontal sinus problems.

Before entering the frontal sinus endoscopically, the anterior ethmoid sinuses are removed. The difficult part is that several of the anterior most ethmoid cells are in an area called the frontal recess. This location is way around a corner, narrow, and must be dealt with very carefully because of its proximity to the eye and brain. Special instruments and techniques are needed to safely remove the last of these ethmoid sinuses. Once all of the ethmoid cells in the frontal recess are removed, one can generally see into the frontal sinus. The size of the pathway to the frontal sinus varies from patient to patient. When it is large, the procedure is relatively easy. When this pathway is narrow, very careful judgment must be employed. The concern is, that this area is so narrow, if it doesn't heal properly, it can heal closed. This goes against the initial purpose of opening up the pathway for enhanced drainage. When the opening is small or is likely to develop polyps or swelling, I usually place small silicone "stents" (tubes) through the passage. These remain for 2 or 3 weeks to prevent the sinus from trying to heal closed in the immediate post operative period.

One premise of the frontal recess is that in my opinion, the surgeon should either leave this area completely untouched, or finish out a complete dissection. Procedures that only partially address this area are more likely to be harmful than helpful.

The frontal sinus is one of the sinuses that may be treatable with the new balloon sinuplasty tools. The indications for using this new instrument depend on the nature of the sinus problem and on several other complicated variables. Balloon sinuplasty has pros and cons as do any of our available techniques and instruments.

Endoscopic Surgery of the Posterior Ethmoids

It is uncommon for infection in the posterior ethmoids to be an isolated problem.The posterior ethmoids are typically involved when there is a pan-sinusitis. Pan sinusitis means that basically all, or many of the sinuses have persistent disease.

The posterior ethmoids are treated very much the same as the anterior ethmoids. The thin walls between the small honeycomb shaped sinuses are removed, turning multiple small spaces into one larger space. Think of a big office room with dividers creating many spaces for individual smaller offices. If you removed the partitions and all of the office furniture, it would be much easier to keep clean. Special caution is needed in the posterior ethmoid sinuses, because they are not as often operated on. Surgeons who only occasionally perform sinus surgery may become disoriented in this location. A fully performed posterior ethmoidectomy is rarely achieved by the surgeons who do not have special interest in sinus surgery.

Endoscopic Surgery of the Sphenoid Sinus

The spenoid sinus is the farthest back of all the sinuses. It is a large sinus, there is one on each side. Some surgeons consider this to be a dangerous and difficult sinus to access, but with adequate experience, it is actually one of the safest and easiest. The spenoid sinus has very reliable landmarks, and it can be visualized by looking straight ahead; unlike the sinuses that require angled endoscopes. Isolated sphenoid sinus obstructions are not too uncommon, but more often the sphenoid sinus is involved when patients have pan-sinusitis.

The work that I do with neurosurgeons, assisting them with access to certain brain tumors by helping them through the sphenoid sinus, provides a great deal of experience that serves my chronic sinusitis patients well. Some surgeons only rarely access the sphenoid sinus, and if problems in this sinus are identified and need surgery, you should ask about their experience accessing the spenoid sinus before any surgery.

The sphenoid sinus is one of the sinuses that may be treatable with the new balloon sinuplasty tools. The indications for using this new instrument depend on the nature of the sinus problem and several other complicated variables.

Everything about
Sinus Surgery

When is surgery

How is modern sinus
  surgery performed?

What is balloon sinus

Does sinus surgery
  really work?

I have had sinus surgery
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  What should I do?

What is the recovery
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Post-operative visits:
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What is a septoplasty?

What is a turbinate

Is packing still necessary?

What are windows?

How painful is modern
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What complications
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