Today’s sinus surgery bears little resemblance to what it was twenty-five years ago. Let’s take a look at some of the major developments that have made the surgical experience less painful for patients and improved the likelihood of postoperative success.

A Brief History

During the first half of the twentieth century, surgeons were hindered by their limited understanding of sinus function, as well as a lack of easy access to the sinuses and nasal passages.

They tended to go directly where the pain was; if a patient’s maxillary sinus kept getting infected, then the inside of that sinus was the focus of the operation.

The surgeon made incisions in the gum of the patient’s upper jaw, scraped out the inflamed sinus lining, and created an artificial passageway for mucus to drain into the nose.

This surgery, which was commonly performed until the 1980s, is known as a Caldwell-Luc procedure. For patients with diseased frontal or ethmoid sinuses, surgery often required a facial incision either just above the eye or alongside the nose that left a scar.

Again, the surgeon opened up the sinus and scraped out the lining. In some cases, the surgeon could operate exclusively through the nose, using a speculum to spread the nostrils and a bright headlight to see inside the nasal cavities.

However, visibility was limited, and it was often a challenge to see and access the depths of the sinuses. To prevent postoperative bleeding, the inside of the nose had to be packed with long strips of gauze.

This packing often stayed in for a week, during which patients could breathe only through their mouths. And the trauma of the surgery left patients bruised and swollen. While these procedures worked for some people, many saw little or no improvement. Why?

One problem was poor visualization surgeons had difficulty distinguishing between diseased and healthy tissue. Another was a lack of understanding of the sinus drainage pathways through the ostiomeatal complex (OMC), the series of narrow channels and openings that serves as a common drainage pathway for the ethmoid, maxillary, and frontal sinuses.

As a result, surgeons often did too much or too little surgery or both. Diseased tissue in the OMC region was frequently left behind, so the sinuses eventually became obstructed again.

And too much normal tissue (such as healthy bone, cartilage, and mucous membranes) was removed, which resulted in the formation of scar tissue and poor sinus function.

Minimally Invasive Surgery

In the 1980s a revolution took place in sinus surgery that led to the development of functional endoscopic sinus surgery, or FESS for short. (Nowadays, many ENT doctors drop the “functional” and simply call it ESS.)

The advantage of ESS is that it’s much less traumatic on the body than older techniques. Patients are no longer left black and blue, and they often don’t need nasal packing.

Those who do can almost always have it removed the following day. The development of ESS was made possible by the nexus of three separate advances: nasal endoscopes, sinus CT scans, and the concept of the OMC. The invention of nasal endoscopes gave surgeons a new technique for accessing the sinuses.

These thin telescopes with highresolution optics allowed for excellent visualization deep within the nose. Instead of cutting through the gums or on the face, surgeons could now enter through the nostrils and get a bright, magnified view inside the sinus cavities.

The 1980s also witnessed a move from plain x-rays to CT scans for evaluating sinus anatomy. For the first time, surgeons could see a picture of the OMC in vivid detail and identify localized obstructions.

This enabled them to do a much better job of evaluating whether surgery was likely to benefit a particular patient. And if it was, they knew more precisely what needed to be done.

Around the same time that nasal endoscopes and sinus CT scans were introduced, an Austrian ENT doctor named Walter Messerklinger proposed a novel idea regarding the cause of sinusitis and its surgical treatment.

According to Messerklinger, frontal and maxillary sinus infections were actually secondary obstructions. The primary cause of sinus obstruction lay in the OMC region of the ethmoid sinuses.

Open up the ethmoids, he said, and the maxillary and frontal sinuses (which drain through the ethmoids) will resume normal function. There was no need to create artificial passageways or to scrape the interior sinus lining.

Messerklinger’s theory was appealing because it meant less extensive surgery could be performed and recovery could be swifter. It was also inviting philosophically, since it meant the final result would more closely approximate natural sinus function. But would it work?

I remember when Dr. Heinz Stammberger, a pupil of Dr. Messerklinger’s, first promoted this new concept to American surgeons at a medical conference in 1985. Many of us in the audience were skeptical. But after practicing the surgery in the laboratory and then performing it on selected patients, we became believers.

As the technique was refined, results continued to improve. By the mid-1990s, ESS was used for the majority of sinus surgeries, and it remains the standard of care today. Now let’s look at the steps of basic sinus surgery, starting with anesthesia.

Anesthesia

ESS can be performed under either local or general anesthesia. The choice depends on the patient, surgeon, and procedure performed. Local anesthesia is administered by injections to the nose, and you receive supplemental sedation through an IV line in your arm.

You may drift in and out of consciousness during the surgery. For general anesthesia, you’re put to sleep with medication administered through the IV line, and you’re kept asleep with a gas you inhale through a tube in your mouth. You have no awareness at all.

Your surgeon may prefer one type of anesthesia or the other. I perform most of my surgeries with patients under general anesthesia, which I find is easier on both the patient and the surgeon. Refinements in technology have made the risk of anesthesia complications extremely low, but it is possible to have an adverse reaction.

You’ll have an opportunity to talk with the anesthesiologist before surgery to discuss any concerns you may have.

The Preoperative Visit

Sometime prior to your surgery, you’ll meet with your ENT doctor to review the details of surgery and sign surgical consent forms. The preoperative visit is a good time to let him know about any recent changes in your overall health.

It will also give you an opportunity to ask any remaining questions you might have about your surgery. You may want to prepare a written list of questions so you won’t forget to ask something important.

If you’re in the midst of a sinus infection, your doctor may prescribe an antibiotic to clear the infection before surgery. Patients are usually advised to stop taking aspirin and aspirincontaining products one to two weeks prior to surgery.

Aspirin thins the blood and increases the risk of bleeding during surgery. You also should not take products containing ibuprofen (such as Advil and Motrin) or other nonsteroidal anti-inflammatory agents within forty-eight hours of surgery.

Arriving for Surgery

When you arrive at the hospital, a nurse will check you in, review your medical history (including drug allergies), and take your vital signs. You’ll also have a chance to meet the anesthesiologist, if you haven’t already done so.

The surgeon may be there as well; if so, you can ask any last-minute questions you may have. When it’s time for surgery, you’ll lie down on a stretcher and be wheeled into the operating room.

Sinus surgery typically requires a minimum of four people: a surgeon, an anesthesiologist, and two nurses. The anesthesiologist will monitor your vital signs, such as heart rate, blood pressure, and oxygen level in your blood.

The scrub nurse hands instruments to the surgeon. The circulating nurse positions you, sets up the equipment, and gets any additional items the surgeon might ask for during the procedure.

Once the anesthesia has been administered, the actual surgery begins. It typically lasts from one to two hours.

The Operation

During endoscopic sinus surgery, the surgeon uses one hand to insert the endoscope into the nose and the other hand to pass a variety of specialized instruments (such as tiny scalpels, curettes, forceps, and a suction device to remove blood and mucus) alongside the endoscope.

For basic ESS, the surgeon proceeds through the following steps:

1. Open the OMC to reveal the site of maxillary sinus drainage.

2. Clear and enlarge the maxillary ostium by removing obstructing tissue, including swollen mucous membranes and polyps.

3. Open the front of the ethmoid sinus (anterior ethmoid air cells).

4. Remove the thin bony partitions and swollen membranes within the honeycomb-like air cells of the anterior ethmoid sinus.

5. If disease extends into the back of the ethmoid sinus (posterior air cells), open and remove diseased tissue in this region as well.

During ESS, the surgeon’s goal is to remove any diseased tissue obstructing the sinuses and causing infections. Ideally, elimination of this obstructing tissue will allow the formerly blocked sinus passages to remain open permanently (see Figure below).

The left side of the diagram shows normal sinus anatomy. The right side shows what things look like after surgery to enlarge the sinus ostia and enhance drainage of the frontal, ethmoid, and maxillary sinuses. Note that removal of the honeycomb-like ethmoid sinuses leaves a much larger passageway through which mucus can now drain.

At the same time, the surgeon attempts to avoid removing normal tissue or mildly diseased tissue that is likely to return to normal once the infected sinus has healed.

The more tissue that is removed, the longer it takes to recover and the greater the risk of complications. Deciding what tissue to remove and what to leave behind is often a judgment call.

The principle I like to follow is “Do as little as possible but as much as necessary.” Samples of tissue removed during surgery are routinely sent to a lab for analysis. In the unlikely event that you have a benign or malignant tumor, it would show up during this analysis.

In the unlikely event that you have a benign or malignant tumor, it would show up during this analysis. Once the surgery is over, the surgeon decides whether to pack your nose, based on the likelihood of postoperative bleeding.

He can use a soft biodegradable substance (which slowly dissolves) or a spongelike material (which is removed later that day or the next morning).

Specialized Instruments

Today’s surgeons have access to a variety of additional tools in the operating room. Whether or not a surgeon uses these devices is a matter of personal preference it’s possible to do effective sinus surgery with or without them.

• Video cameras. Although the surgeon can perform the operation by looking directly through the eyepiece of the endoscope, nowadays most surgeons operate with the help of a tiny video camera.

This camera, which is attached to the endoscope’s eyepiece, displays a magnified image of the nasal interior on a video monitor. The surgeon performs the operation while looking at the monitor.

• Microdebriders. A microdebrider (also known as a microdissector or shaver) is a thin hollow tube with a rotating blade at one end and a suction device at the other.

The surgeon activates the blade with a foot pedal and shaves away tissue, which automatically gets suctioned down the tube. Such motorized instrumentation was first used by orthopedic surgeons to shave cartilage during knee surgery.

Microdebriders were adapted for sinus surgery because of the efficient manner in which they remove polyps and swollen membranes.

Some surgeons use microdebriders for all their sinus surgeries. I prefer to use them for selected cases, such as for patients who have large polyps.

• Lasers. Lasers use an intensively focused beam of light to vaporize tissue and simultaneously seal blood vessels a combination that makes them ideal for surgeries requiring precise tissue removal.

When ESS was first introduced, many surgeons used lasers to perform the procedure. However, because lasers remove tissue by burning rather than cutting, patients who underwent laser ESS were found to have more swelling and congestion during the postoperative healing period.

As a result, lasers are now used infrequently for sinus surgery. Nevertheless, they remain an effective tool for bloodless removal of swollen tissue, particularly in patients who have enlarged turbinates.

Advanced Techniques

As has been noted, most sinus surgeries center on the OMC and the maxillary and ethmoid sinuses. However, in patients with frequent infections of the frontal or sphenoid sinuses, it may be necessary to do more extensive surgery.

Not all ENT doctors perform the more advanced techniques, so patients who need one of the following procedures may be referred to a surgeon specializing in difficult cases.

• Sphenoid sinusotomy. If an infected sphenoid sinus doesn’t clear with medications, a surgeon can choose to enlarge the sphenoid ostia and drain entrapped fluid.

Because of the sphenoid’s sensitive location near the optic nerve and brain, this surgery can be delicate. Nevertheless, when properly performed, it is a safe and effective way to treat sphenoid sinusitis.

• Frontal sinusotomy. Here, the surgeon uses endoscopic instruments through the nose to open and enlarge the frontal sinus ostia. The frontal sinuses are more difficult to reach because of their location high up in the forehead.

Surgeons must use longer, curved instruments and endoscopes with angled views. Although a frontal sinusotomy is more complex than standard surgery, it is usually successful at relieving frontal headaches.

• Frontal sinus drillout. If a frontal sinusotomy doesn’t work or if the surgeon suspects it won’t another option is to remove the entire bony floor of the frontal sinus with a drill passed alongside the endoscope.

This surgery, also known as a Modified Lothrop procedure or a Draf 3 operation, creates a very large opening between the frontal sinus and nose, maximizing mucus drainage.

It takes longer to perform than normal sinus surgery, and healing can also take more time, because of the amount of bone removed.

• Frontal sinus obliteration. An alternative treatment for frontal sinusitis is elimination of the frontal sinuses altogether. Some people never develop frontal sinuses, and they get along just fine.

Frontal sinus obliteration is performed through an incision in the scalp or forehead. The surgeon makes an opening through the bony sinus wall, removes all the tissue inside with a drill, fills up the empty sinus with a piece of fat taken from the abdomen, and then reseals the sinus.

When healing is finished, fat cells completely fill the sinus, and there is no longer any air-containing sinus cavity to become infected.

Although frontal sinus obliteration is much more invasive than conventional endoscopic sinus surgery, it has been performed for more than thirty years and has a longterm success rate of more than 90 percent.

Recently, I have begun performing frontal sinus obliteration with an endoscope and drill passed into the frontal sinus through a small incision in the eyebrow.

This minimally invasive approach may prove useful for selected patients with small-or medium-sized frontal sinuses, but the long-term success rate is not yet known.

Image-Guided Surgery

Image-guided surgery is a recent development that you may benefit from, particularly if you have an advanced procedure. Here, the same Global Positioning technology that directs drivers to their destinations and missiles to their targets is used to help surgeons guide their instruments through the sinus cavities with millimeter accuracy.

Image-guidance systems enable a surgeon to monitor the precise location of his instruments within the sinus cavities throughout surgery. These systems use either an infrared beam or an electromagnetic signal to track the position of the instruments relative to the patient’s head.

They require the patient to wear a special headset during surgery. (For some image-guidance systems, the same headset is worn by the patient during the preoperative sinus CT scan.)

The location of the tip of the instruments is depicted by crosshairs on a three-dimensional video display of the patient’s sinus CT scan, as shown in Figures below.

With the left hand, the surgeon holds a video camera attached to an endoscope that displays a magnified view of the nasal cavity on the video monitor (right). With the other hand, he passes instruments alongside the endoscope to remove diseased tissue. The image-guidance system uses an infrared camera (horizontal white bar at top) to monitor the location of the tip of the surgical instrument, which is displayed on a second video monitor (center).

Image-guided surgery’s advantage is that it reduces the element of guesswork the surgeon always knows exactly where he is. For this reason, it’s most helpful in difficult cases.

During a study of one thousand image-guided sinus surgeries, I surveyed forty-two surgeons who used this new technology at the Massachusetts Eye and Ear Infirmary from 1996 to 2002.

The video display of an image-guidance system during sinus surgery shows the location of a surgical instrument depicted by crosshairs on three different views of the patient’s CT scan. The lower-right quadrant shows a three-dimensional reconstruction of the patient’s sinus anatomy, with the tip of the surgical instrument (depicted as a black pointer) in the ethmoid sinus.

They found it to be particularly helpful in cases where the normal surgical landmarks were absent, a common occurrence among patients who have extensive disease or who have undergone previous surgery.

Although image-guidance systems have the potential to enhance surgery’s safety and efficacy, they also have drawbacks. Like any fancy new computer, they take time to master, and bugs in the system sometimes arise.

Also, these systems add time and expense to the operation, so they are not meant to be used for routine sinus surgery. Now that you know what surgery involves, let’s examine what you can expect in the days, weeks, and months afterward.