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Nasal Septal

There are two basic categories of problem that end up having sinus surgery. The first group of patient are those who have a dangerous situation with their sinuses. Having to perform sinus surgery for urgent or emergency problems is relatively uncommon. The second category includes patients who have taken many of the appropriate recommendations to treat their sinus problem and continue to have problems that impact their life significantly. The problems need to be persistent enough to warrant going through an outpatient surgical procedure.

Indications for Sinus and Nasal Surgery

Chronic Persistent Sinus Problems

The most common indication for sinus surgery is in people who just keep a chronic problem despite treatment. The most common problem is called Chronic Sinusitis. This term really can cover several different pathologic entities, but they all have in common that there is material of some sort that is stagnant in the sinuses for greater than 45 days, and won't easily respond to medicine and is inflamed.

The most understood of these problems is when one or more of the sinuses develops an infection with bacteria, and then goes on to develop a "vicious cycle" that prevents it from easily clearing. The vicious cycle of chronic bacterial sinusitis often goes like this.

It is at point D when most people present to a specialist for help with their problem. By this time (usually greater then 45 days), the infection is such that the usual measures used to treat acute sinusitis will not work. A specialist can help with this vicious cycle by surgically improving drainage and removing some of the chronically infected thin layers of bone.

Before considering surgery as the next step, your specialist will want to try more aggressive medical therapy; it will often be successful where the common therapy has failed. Aggressive medical therapy & evaluation may include one or more of the following:
    - Prolonged broad spectrum antibiotics (3 - 6 weeks, or more, with no gaps)
    - Oral steroids such as a medrol dosepak or prednisone, when indicated
    - Steroid sprays, almost always
    - Bacterial cultures to look for resistant bacteria, if this is suspected
    - Radiologic studies that may include plain x-rays or CT scans
    - Endoscopic examination of the nasal passages and sinus openings
In patients who have already had sinus surgery

The the workup is quite a bit different and often begins with an endoscopic exam and an attempt to identify the nature of the problem and often to obtain culture material of any infection.

There are other underlying pathologic processes that cause the same symptoms and basically end up with the same workup and treatment. Allergic Fungal Sinusitis is probably the most common of these problems. Currently, we do not fully understand the entire pathophysiology of this problem and it is well appreciated that it can be hard to fully diagnose and treat. Despite these limitations, most people with Allergic Fungal Sinusitis will end up with improvement or cure from a detailed treatment plan. With full blown AFS, the treatment plan usually ends up including some surgical procedure.

Recurring Sinus Infections

Another indication for sinus surgery is in patients who can fully clear their problem, but who continue to get repeated bacterial infections. Important points to consider in such patients are:

1- It is necessary to have clear evidence of bacterial infection or of some clear anatomic obstruction. Some patients may get frequent viral infections or severe allergic flare-ups and mistakenly be treated for bacterial infections. In such patients, surgical procedures would be of little benefit.

2- The infections need to have significant symptoms and cause significant loss of work, school, or other important activities. If the problem is mild and easy to treat, one should simply treat the problems as they come.

3- There is no official frequency of infections that would put someone into a category that they might consider a surgical workup, but a frequently quoted rule of thumb is listed below:
  • Four or more episodes of infection during the past 12 months
  • A trial of immunotherapy for allergic rhinosinusitis in those who have a history that suggests allergy.
  • Presence of an anatomic variant, especially one causing obstruction         and/or
  • Prophylactic use of nasal steroids, mucolytics, and decongestants without benefit
Patients with clearly defined anatomic explanations (by CT usually) for their repeated infections are basically the very best candidates for surgery. The procedure is usually very minimal, the recovery time brief, and the results are usually long lasting.

In patients in whom no specific anatomic abnormality can be identified, the results range from dramatic resolution of the problem to no significant benefit. Predicting the success is difficult when no discreet anatomic abnormality is identified. If such patients also have nasal airway obstruction, one can be fairly sure to improve this issue even when infections continue to occur. In addition, in patients who have had such procedures, it is often the case that the infections are quicker clear than they were before and have less pain associated with them.

Frequent Headaches of Sinus Origin

This is a common reason to visit a sinus specialist; it can also be one of the hardest problems to diagnose and treat. I tend to think of such patients as falling into three categories.
  • Those in whom a very clear and obvious source of the sinus headache can be found
  • Those in whom no clear sinus based explanation can be found for the headaches
  • Those who have some abnormality that could be responsible for the headaches, but whose story also suggest that non sinus origin headaches could be present too or instead.
It can be very difficult to determine what the source of headache pain is. Doctor and patient can be fooled into believing that sinus origin problems are the root of the headaches, and it may later prove that that is not really the case.

  • Those in whom a very clear and obvious source of the sinus headache can be found.

  • If a clear problem is identified, such as chronic infection, then the next steps are generally straightforward. The patient and doctor attempt additional medical therapy for the problem. If the problems don't clear up with medications, surgical options are discussed. CT scans are almost always part of the workup and of the follow up for medical treatment of sinus origin headaches.

  • Those in whom no clear sinus based explanation can be found for the headaches

  • In patients that have no identifiable anatomic source for their "sinus headaches" it is best to seek out neurologic consultation and then embark on a workup for non sinus headaches and proceed with treatment for such. There are times when the patient is absolutely certain that the pain is coming from the sinuses, despite CT scans and physical examinations being unable to provide an explanation. When this is the case, it is still best to treat this type of pain as if it were a "head" headache.

    Doctors should be careful to avoid saying things like "Well, your sinuses are clear, you don't really have sinus headaches." I would propose that just because a scan or exam is normal, that doesn't rule out the sinuses are a source of the pain. As a thought experiment, consider that in most cases of "head" headaches, the MRI scan of the brain is normal, but that doesn't mean that there isn't any pain. It is still the most reasonable route to treat this problem like a "head" headache.

  • Those who have some abnormality that could be responsible for the headaches, but whose story also suggest that non sinus origin headaches could be present too or instead.

  • Some sinus headache patients have some abnormality that we know can cause sinus headache pain. One example is a Concha Bullosa . If the nature of the headaches or the nature of the abnormality is such that the correlation is uncertain, this can become quite confusing for patient and doctor. The doctor shouldn't dismiss the possibility that the abnormality is causing the pain, neither should they appear to be certain; it's just not that easy.

    In most cases such as this, it is wise to try medical therapy for some period of time. Steroid sprays, mucous thinners, and allergy treatments might be tried. Some trial period of standard headache treatment might be tried and may even include neurologic consultation. If things don't improve, it may be appropriate to proceed with surgical intervention. In these cases, the patient needs to be fully aware that the outcomes are not guaranteed.

    The way I put it (and lets use a concha bullosa as an example) is:"If the headaches are from this concha bullosa , and we know that in some patients they are, then we can fix this with a minor surgical procedure. Some patients, however, have a concha bullosa and have no symptoms at all, so the correlation isn't always compete. Basically the only way to know for sure, is to do the operation and see how it goes."

    Airway Obstruction

    Some cases of nasal airway obstruction are from specific anatomic abnormalities. Examples are nasal septal deviations, adenoid hypertrophy, prominent turbinate hypertrophy, and nasal polyps. When the airway doesn't respond to medical therapy, such as steroid nasal sprays, surgical intervention is often suggested. It shouldn't be a luxury to breath through your nose. Fortunately, getting people to be able to breath through their nose is one of the most reliable outcomes of nasal and sinus surgery.

    Dangerous Sinus Problems that need Surgery

    There are a couple of uncommon problems that really do need sinus surgery. Most of the problems listed above, you can live with, the ones listed below, you cannot.
    • Infection that spreads outside of the sinuses and forms an abscess, (orbital abscess, brain abscess, meningitis, or subperiosteal abscess) then surgery can be life saving.
    • If some type of cyst is eroding through the bone that separates the brain from the sinuses, this can be an absolute indication for surgery.
    • Sinus tumors that need diagnosis and or treatment are an indication for surgery.
    • Spinal fluid leak is an indication for surgery, this would usually be related to a previous sinus surgery (very rare complication) or some type of head injury.

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