Sinus Surgery

So you’ve tried just about every sinus medication, including repeated courses of antibiotics, and you’re still no better. Now what? For some people, an operation to open and drain blocked sinuses can have a dramatic effect. But how do you know if you’re a good candidate for surgery?

Because sinusitis is not a life-threatening condition, deciding whether to have surgery is not black and white but, rather, shades of gray. Let’s look at some of the issues that arise as you and your doctor make this important decision.

Your Doctor’s Recommendation

Your ENT doctor bases his recommendation on your history, endoscopic exam, and CT scan findings. (I’ll use the terms ENT doctor and surgeon interchangeably because it’s the ENT doctor who performs the surgery.) A key issue is the number of annual infections.

As a rule of thumb, it’s time to consider surgery if you have four or more sinus infections each year. If this is the case, you’re spending a large percentage of your time suffering and recovering from infections, so surgery’s benefits are likely to be tangible.

Another consideration is the duration of your infections. Over time, some people find that infections that formerly lasted a few days are now lasting several weeks because antibiotics are less effective. Surgery may still be advisable for someone who has only two or three infections a year if they last several weeks or months.

Older people often wonder if their age should be a factor in deciding whether to have sinus surgery. As long as you’re otherwise healthy, advancing age should not discourage you from surgery. I’ve operated on many people in their eighties with positive results.

It’s Your Decision

If your doctor advises that you are likely to benefit from surgery, then you need to think about whether surgery’s potential benefits outweigh its discomforts and risks. Here, the key issue is quality of life. Think about how sinusitis affects your day-to-day ability to function. How many sick days from work do you take?

Does sinusitis affect your social life? Are you often tired? How do you feel about the amount of medication you take? Would your enjoyment of life change appreciably if you had fewer infections? It’s a very personal decision.

One individual may find that missing two to three weeks of work each year for sickness is acceptable, while another feels it prevents him or her from reaching important career goals. The more you feel sinusitis is affecting your quality of life, the more the pendulum swings in favor of surgery.

Realistic Expectations

It’s important to have realistic expectations of what the procedure is likely to accomplish. Bear in mind that for most patients, sinus surgery does not provide a complete cure. Some sinus infections will still occur, but the frequency and severity of infections will be reduced.

If you’ve had five or six sinus infections each year, surgery often can reduce the number to two or three. Not every cold will turn into another case of sinusitis. And if the procedure is successful, infections that do occur will be of shorter duration; a briefer course of antibiotics will control your symptoms.

You should also be aware that surgery will not eliminate the underlying cause of your sinus problems. If you have allergies, surgery does not cure them, so symptoms such as itchy eyes, sneezing, and thin postnasal drip are likely to remain, along with the need for allergy medications.

And while surgeons can remove polyps, they can’t eliminate the problem that causes them to grow. So individuals with large polyps are likely to need additional surgery when polyps regrow. One thing that’s hard to predict is whether patients whose sense of smell has been impaired by sinusitis will regain this function.

It depends on the cause of the defect. If repeated infections and polyp growth have severely eroded the nerve endings on olfactory receptors, then smell is not likely to return after surgery.

If, on the other hand, loss of smell is caused by polyps and swollen tissue that block odor molecules in the air from reaching the smell receptors in the back of the nose, then removing the polyps and obstructions should lead to a return in smell.

In terms of the Sinusitis Spectrum (see Figure below), Locals whose CT scans show limited obstruction of the sinuses usually respond well to surgery because the anatomical cause of obstruction often can be permanently eliminated.

The likelihood that surgery will be curative or will need to be repeated corresponds to the location of one’s disease along the Sinusitis Spectrum.

In many cases, normal sinus function is restored. Systemics whose sinusitis is caused by polyps or extensive mucosal swelling can expect improvement, although without a complete cure. The nose and sinuses will be more open, but underlying inflammation of the mucous membranes lining these passages will remain.

The long-term success of sinus surgery for Intermediates varies, depending on whether the severity of their disease places them closer on the Sinusitis Spectrum to Locals or Systemics.

Surgery Really Does Help

Although it’s important to have realistic expectations, I don’t mean to downplay surgery’s genuine benefits. Two studies I conducted with Dr. Richard Gliklich and my colleagues at Harvard University offer insight into how surgery affects people’s lives.

The first study, published in 1997, followed more than one hundred patients who underwent surgery for chronic sinusitis. They rated their symptoms (such as headache, congestion, and drainage) before surgery and afterward at regular intervals for one year.

They also reported on use of sinus medications and completed questionnaires about how sinusitis affected their quality of life. Overall, 82 percent of patients were found to have significant improvement following sinus surgery. The second study, published a year later, focused exclusively on the economics of sinus surgery.

We found that the cost of sinus medications—including prescription and over-the-counter remedies— averaged $1,220 per patient per year before surgery and $629 after surgery, a 48 percent reduction.

Because surgical techniques have continued to improve in the past decade and more sinus medications are now available, I suspect that both the 82 percent symptom improvement rate and the 48 percent reduction in medication costs would be even greater if we conducted similar studies today.

Factoring in Complications

An additional factor to consider when contemplating sinus surgery is the risk of complications. Although technological advances have reduced the incidence of surgical complications, the element of risk can never be completely eliminated. Here’s a list of complications associated with sinus surgery, starting with the most common:

  • Bleeding. The nose and sinuses are prone to bleeding during and after surgery because they have a rich blood supply. If bleeding does occur, it can usually be controlled by nasal packing.
  • Infection. Bacteria can multiply on the raw tissue and crusts that are present in the nose after surgery, leading to a sinus infection. A doctor can treat such infections with an antibiotic and by cleaning out the nose.

Bleeding and infection each occur in about 5 percent of patients. Some rarer complications include:

  • Impaired breathing. Temporary nasal congestion from swelling is expected after surgery. Long-term nasal airway obstruction may occur if dense scar tissue forms after surgery and blocks the nasal passages.
  • Loss of smell. Many patients have a decreased sense of smell for a week or two following surgery because of swollen nasal membranes. Long-term impairment may result if the region of the olfactory nerve is inadvertently damaged during surgery or if dense scar tissue forms and blocks odor molecules from reaching smell receptors in the nose.
  • Excessive tearing. The duct that drains tears from the eye into the nose runs through the wall of the maxillary sinus. If this duct is injured during surgery, excessive tearing may result, requiring additional surgery to restore proper tear drainage.

Very rare but serious complications include the following:

  • Spinal fluid leak. If the layer of bone separating the sinuses from the brain is breached during surgery, the clear cerebral spinal fluid (CSF) that surrounds the brain can leak into the nose. If this leak persists, the patient risks developing meningitis, which can be life-threatening.

A CSF leak can be closed immediately if it’s recognized during surgery. If it’s not, additional endoscopic surgery to close the leak will likely be needed. Such corrective surgery is generally performed through the nostril and involves placing a tissue patch over the leakage site.

  • Decreased vision. Injury to the eye itself or the surrounding muscles and nerves may leave patients with impaired vision, including double vision or blindness.
  • Stroke. The carotid arteries run through the walls of the sphenoid sinuses. If one is injured during surgery, blood flow to the brain may be interrupted, resulting in a stroke.

Although these last complications sound frightening, it’s important to realize that they are extremely rare. Your doctor will review all potential complications that apply to your surgery and answer any questions you may have. Deciding whether you’re a good candidate for surgery is an important first step.

Now, let’s look at what sinus surgery entails.