Sinusitis and Functional Endoscopic Sinus Surgery – July 2011

It is estimated that 40 million Americans are affected by disease of the sinuses annually, costing our healthcare system in excess of 6 BILLION dollars, without taking into account the financial burden of lost time from work.  At one time or another, we all suffer from a sinus infection. However, there are those for whom recurrent sinusitis is a way of life, and disabling.  On rare occasion, sinus infection can result in fatal or near-fatal consequences. In my specialty (ENT, or Otolaryngology), there is a systematic approach to the treatment of sinus disease.  Our goal is to return people to a reasonable quality of life, to diminish dependence on chronic medication and to avoid more serious complications.

“Sinusitis” strictly speaking means inflammation of the sinuses, but the term has come to be understood as actual infection of these structures.  Sinuses are air-containing spaces in the facial bones that are attached by thin drainage tubes to the nasal passage (see diagram).

The frontal sinuses are above the eyes in the lower forehead, the maxillary sinuses are within the cheek bones, and the ethmoid sinuses are between the eyes.  The sphenoid sinuses are over 3 inches back from the tip of the nose just below the brain. Infection of the sinuses is usually caused by a blockage within the nasal passage that inhibits normal draining from the sinus.  Secretion backs up in the sinus and creates a perfect environment for bacterial overgrowth.

The usual symptoms of sinusitis are facial pain or headache, coupled with discolored (usually yellow or green, sometimes bloody) discharge down the throat or from the nose.  Often, this is accompanied by severe nasal congestion, and feeling of general illness.  Other symptoms include sore throat and cough.  Fever may be a sign of more advanced infection.  Initially, the diagnosis of sinusitis can be made on physical exam in addition to the description of symptoms noted above.  It is unnecessary initially to obtain xrays or scans before treatment.  I am able to diagnose sinusitis by using a 2 millimeter fiberoptic scope through the nose, and actually see the drainage of pus from the sinus openings.

Initial treatment of a sinus infection should include an antibiotic given orally for at least 10 days to 2 weeks, coupled with aggressive nasal saline irritations (NeilMed, or Neti Pot) four times a day.  I recommend a generic, broad spectrum antibiotic (cefuroxime, trimethoprim/sulfamethoxazole, Augmentin) that covers the usual bacteria which we know cause these infections.  I usually will start patients on a steroid nasal spray (fluticasone, monomethasone)  and continue it for at least 6 weeks.  If the infection symptoms persist, a different antibiotic can be selected and the treatment duration extended.

The patients I see in my practice are those who have been through numerous cycles of infection, and who have been treated properly, but continue to get infected.  For these individuals, a thorough ENT exam, including fiberoptic exam of the sinuses is needed.  Usually, at some juncture, we order a CAT scan of the sinuses to better understand the degree of disease, and to identify obstructions in the sinus passages that result in these stubborn recurrent infections.

Functional Endoscopic Sinus Surgery (FESS)

Prior to the mid-1980’s, sinus surgery was performed, at times, in a radical manner.  Excessive tissue was removed unnecessarily from the nose and sinuses, creating scarring and actually preventing normal sinus function.  About 25 years ago, a new philosophy in sinus surgery took hold – to remove minimal tissue, open the natural drainage pathways of the sinuses and allow them to recover normal function.  Fiberoptic systems allow us now to see in great detail areas in the sinus anatomy through the nasal passage by the use of
fine, rigid “scopes”.  By working along side these scopes with fine instruments, a far less invasive procedure can be done in less time.  The results of FESS are consistently better than we have seen in decades past.  Computerized image guidance systems allow us to “stereotactically” work in sinus regions near the brain and eye safely.

It is my estimate that over 90% of carefully selected patients that undergo FESS will see significant relief for years.  While it is possible many of these patients will need to continue some form of medical treatment such as the use of steroid nasal sprays, and saline nasal rinses, a vast majority will look back on their endoscopic sinus surgery as a positive change
in the health.  These surgeries are done in less than one hour under a brief anesthetic, and the patients are discharge within an hour of the end of surgery as a rule.  As a rule, our patients have no packing that requires removal, almost never show bruising or swelling and can return to moderate activity within a day or two.

Since each and every patient with sinus disease is in their own way unique, I “tailor” their treatment to their condition and try to offer my patients a range of options, both medical and surgical, before embarking on treatment.

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