One of the most common afflictions in modern life is sinusitis, with literally tens of millions of Americans afflicted every year. Billions and billions of dollars are spent on over-the-counter medications, prescriptions and lost worker productivity. It appears that the incidence of sinusitis, like that of the related disease asthma, is increasing dramatically. Appropriate therapy can greatly reduce the symptoms and frequency of sinus attacks in the great majority of sufferers.
Dr. John Burgoyne and Dr. Calvin Knapp are highly experienced in the diagnosis and treatment of sinus disorders, including treatment of allergies. The most up-to-date advances in sinus surgery are available through our center.
What are Sinuses?
The sinuses are large, air-filled cavities within the bony structure of the face surrounding the nose. Normally humans have four sets of sinuses. The frontal sinuses are in the forehead.
The maxillary sinuses are behind the cheekbones, and are the most well-known sinuses. The ethmoid sinuses are between the eyes and eye-sockets in the middle of the face. The ethmoid sinuses are actually a honeycomb of a dozen or so compartments connected together. The sphenoid sinuses are at the back of the nose, behind the eye sockets, nearly in the center of the head.
The sinuses are lined with mucosa. Like the mucosa elsewhere in the nose, the sinus mucosa has thousands of tiny hair-like structures called cilia, which beat rhythmically about 1,000 times a minute, sweeping the mucous produced by the sinuses out into the nasal passages and backwards into the throat where it is swallowed. Normally, humans will produce about a quart and a half of thin, watery mucous every day. This is not usually noticed unless it becomes thickened or infected. The constant flow of mucous sweeps the bacteria and dust particles out of the sinus, and keeps them clean and nearly sterile.
The openings of sinuses are generally very small, and problems occur when the mucosa lining the openings thickens to the point of blocking that opening. Mucous and bacteria are trapped in the sinus, and an infection starts. The infection in turn will lead to more swelling, and can develop into a cycle that is hard to break. It is interesting that most of the sinuses drain out through the small area behind the middle turbinate. The openings can also become blocked if the middle turbinate is too large, or is pushed to the side in front of the openings by a deviated septum.
In some patients, the mucosa will swell up so much that it will hang down in large folds or bags of tissue. These are called polyps. Nasal and sinus polyps are rarely actual growths, and thus are almost never cancerous or malignant. Polyps contribute to sinus problems by either blocking the openings into the sinuses, thus worsening the cycle of infection, or by being large enough to block the nasal airway.
What is Sinusitis?
When bacteria are growing inside the sinuses, that is called sinusitis. It is almost always due to a blockage of the drainage opening in the sinus. A person’s susceptibility to sinusitis is based on the size and shape of their sinus openings, and also to their propensity for thickening of the tissues of the nose and sinus. If the lining tissue thickens due to a cold, allergies, or other irritants, then the openings can become blocked, thus trapping bacteria in the sinuses, causing an infection. The infection itself will lead to more swelling, and a vicious cycle can develop – swelling leads to infection, which leads to more swelling which leads to more infection.
Common symptoms of sinus infection are: headache, face ache, or tooth ache; thick discharge, often yellow or green; nasal congestion or stuffiness; fatigue; post nasal drip and cough or hoarseness; flare-up of asthma, bronchitis, or pneumonia; ear pressure; decreased sense of smell or taste; feeling of a lump in the throat; bad breath; worsening of snoring; and disequilibrium.
When sinusitis goes on for a while, the lining tissue may become permanently thickened, so that the openings are always partially or completely blocked. With time, the entire sinus system can fill up with thickened tissue. This thickened tissue may hang down into the nose. These are called polyps. People with asthma are particularly prone to developing polyps.
Rare complications of sinusitis come when infection spreads into the surrounding organs, namely the eyes or brain. Meningitis, brain abscesses, and eye-socket abscesses can occur.
Sinusitis is defined as acute if it last less than 6 weeks. Some patients have recurrent attacks of acute sinusitis, but their sinuses clear out completely in between attacks. If the symptoms last for more than 12 weeks, or if the sinuses don’t clear completely between acute attacks (as evaluated by physical exam or CT Scans), it is referred to as chronic sinusitis.
Evaluation of the Sinus Patient
The evaluation of the nose and sinuses starts with the medical history. The pattern of nasal obstruction, infections, pressure, etc., are all important and contribute to understanding the disease process.
The examination consists of looking into the nose, first from the front using a headlight or reflecting mirror. This gives information regarding the size and shape of the turbinates, as well as the shape of the septum. Sometimes a decongestant spray is used to shrink the mucosa and allow a better view.
Nasal endoscopes are used to look farther into the nose, and to look at the openings of the sinuses. Endosopes are special telescopes which show the insides of the nose in greater detail.
A CT Scan is a special type of x-ray which gives a cross-sectional view of the nose and sinuses. This gives a very detailed picture of the anatomy, and can show if there is any septal deviation, enlarged or abnormal turbinates, and most importantly allow the physician to evaluate whether there is ongoing thickening of the sinus mucosa, or any polyps or fluid.
Treatment of Sinus Problems
The goal of medical treatment for nasal and sinus problems is to prevent or reverse abnormal swelling of the mucosa and eliminate infection.
Nasal steroids (Rhinocort Aqua®, Nasacort®, Flonase®, Nasonex® and others) are medicines that are sprayed into the nose. They will shrink swelling from any cause, and are safe for long-term use. Steroids (prednisone, Medrol®, and others) may also be taken by mouth. These drugs may dramatically shrink swollen tissues, but are not suitable for prolonged use because of serious side effects.
Antihistamines, either orally (Allegra®, Claritin®, Clarinex®, Zyrtec®, Benadryl®, and others) or sprayed into the nose (Astelin) will help prevent swelling due to allergies.
Over-the-counter 12-hour nose sprays such as Afrin® or Dristan® will shrink the turbinates well, but are only safe to use for a very short time. Prolonged use will lead to rebound swelling that will lead to dependency on the sprays and complete obstruction of breathing if they are withdrawn. We usually only use these in very short-term situations, such as around the time of surgery, or before airplane flights, or sometimes right at the start of treatment for an infection.
A large range of antibiotics are available, and are very helpful in fighting sinus infections. These are frequently most effective when used in combination with some of the other treatments. A several-week course is needed for severe or chronic infection.
Salt water (saline) rinses are useful for washing thick or infected mucous out of the nose. Normally, almost none of a saline rinse actually gets into the sinuses.
Allergy testing is very useful for treatment planning. Between one-third and one-half of all people will have some degree of allergy, and the proportion is higher in those with chronic sinusitis. Things to which we are allergic are called allergens.
Skin testing is an accurate method of determining a patient’s allergies. Blood tests are best for testing some types of allergies. At the Seattle Sinus and Allergy center we use a combination of these methods.
Allergy treatment usually will include avoiding or eliminating the allergens by environmental control, which can include special air cleaners or filters, mattress covers, and cleaning.
Antihistamines are also used to control allergies.
Many allergens are difficult or impossible to avoid, and immunotherapy, or allergy shots, are used. These are made from the specific antigens that the patient had reactions to, and are given weekly for a period of time. Immunotherapy is effective because it actually reduces the body’s response to the allergens.
Nasal and Sinus Surgery
Surgery to improve breathing can consist of straightening the septum (septoplasty), reducing the size of the turbinates (turbinectomy), or enlarging the openings of the nose with spreader grafts.
Septoplasty is done by raising the mucosa off of the cartilage and bone of the septum, and then removing the portions that are crooked or out of alignment. The cartilage removed can be re-shaped and replaced, or discarded if not needed for support.
Spreader grafts involve placing tissue harvested from other parts within the nose to enhance the airway and prevent collapse.
Turbinates can be reduced by literally trimming them with special scissors, cauterizing (burning) the mucosa to cause it to shrink, freezing the mucosa (cryotherapy), or radiofrequency treatments.
The goal of surgery is to reduce sinus infections, pain or pressure. The sinus openings are made large enough that they will remain open.
Infected mucous or diseased mucosa can then be cleaned out. The majority of sinus patients will require septoplasty, turbinectomy, or spreader grafting along with the sinus operation.
Most sinus surgery is done using endoscopes, special surgical telescopes that allow the surgeon to see into the nose and make fine alterations in the anatomy. This technology allows almost all sinus surgery to be done through the nostrils. It brings about quicker recovery and less pain and bleeding than the older methods, and is very safe.
Surgery today is usually done under general anesthesia, meaning that the patient is completely asleep for the procedure. Patients who are otherwise healthy can usually go home the same day, and be back at work within a week. People who do heavy lifting in their jobs will need to be off work longer.
Outpatients usually have surgery at the Minor & James Surgery Center, located in our offices. This is a Medicare-certified surgery center, and our anesthesiologists are from Physicians Anesthesia Service, the group which also provides care at Swedish Medical Center. Some of our patients will have surgery at Swedish Medical Center (either the First Hill or Providence campus).
Patients arrive about 45 minutes prior to surgery, which allows time for the nursing staff and anesthesiologist to interview and evaluate the patient. The surgeon will answer any last-minute questions or concerns. Surgery will last from 45 minutes to 90 minutes, depending on the extent of the procedure. Patients are usually ready for discharge about 1 to 1.5 hours after surgery.
Nasal surgery usually requires some form of packing to prevent bleeding. Pressure packs stop bleeding by applying pressure, and are usually removed the next day, either by the patient at home or by the surgeon in the office. Gelatin (Gelfoam) packs work by sticking to the surface and encouraging clotting. These packs are not removed, and will either slowly dissolve, or come out on their own after several days.
Internal splints may be used to hold the septal mucosa flat and straight. These stay in for about 5-7 days, and are removed in the office.
Patients will have some degree of minor bleeding and nasal crusting for several weeks after surgery. Irrigation with salt water and frequent visits to the surgeon’s office are needed to prevent build-up of uncomfortable crusts which can block breathing and allow infection.
Unless a cosmetic change in the appearance of the nose is being made, there is generally no significant visible swelling or bruising. Discomfort is mild to moderate, and most patients will take narcotic pain pills for a few days.
It is common for the sense of taste and smell to be diminished or even absent for a few days to weeks after surgery. This is due to swelling, and rarely persists. Pain or numbness in the front teeth is also common, and again resolves within a few weeks.
Strenuous exercise and airplane flights are restricted for two to four weeks (check with your surgeon), although light exercise such as walking is acceptable as soon as the patient feels up to it.
As in any procedure, there is always the possibility of complications. Bleeding which could require additional packing occurs in 1-2% of patients. Since there are a lot of bacteria in the nose, infection is also possible, although it is infrequent. All patients are kept on antibiotics for a period of time after surgery, and sometimes a change in antibiotics is needed.
Serious or life-threatening bleeding or infections are very rare. Even more rare would be complications related to the structures surrounding the nose and sinuses, namely the eyes and brain. These have been nearly eliminated by the modern endoscopic techniques. Overall, nasal and sinus surgery is extremely safe.
Nasal surgery to improve breathing is very successful, with 95% of patients being satisfied with their breathing. Minor revisions will usually help the remaining few patients to achieve good results.
Sinus surgery is also very successful, although because the surgery cannot correct the allergic problems or other mucosal abnormalities, ongoing therapy is needed in some cases. Patients with polyps in particular need meticulous follow-up care and treatment, and this can be a recurring problem.
Your surgeon can give you personalized information about your procedure, and answer any questions you may have.