Consultation for Sinusitis and Endoscopic Sinus Surgery This consultation is part of a series of consultations with Head and Neck Surgery specialists at the University of California, San Diego. The case is a hypothetical patient chosen to represent a composite of the usual and most common patients with this specific disorder. Where gender, age or race make a difference, these will be specifically cited. Where they do not make a difference, they may be omitted. The consultation is presented for purposes of general information. Specifics about an individual case and specific treatment must be discussed between the patient and the treating physician. The patient is a young adult referred for evaluation for chronic sinusitis Doctor: Good morning. What can I do for you today? Patient: I have suffered recurrent sinus infections. My primary care physician has been unable to successfully manage these and has recommended an evaluation to see if you have additional ideas. Doctor: How long have you been having recurrent infections? Patient: I have been having sinus infections for the past 5 to 10 years. Doctor: What are these infections like? Patient: Well, they just sort of come on and then I get pain and pressure in my face and about my eyes. I generally feel tired and somewhat lethargic. I feel like I cannot breathe, and very often I will get a nasty, foul-tasting greenish-yellow discharge down the back of my throat. When I can no longer tolerate the pain, I go to my primary care physician. The diagnosis of sinusitis is made, and he gives me antibiotics. Doctor: How long does it take for the sinus infections to resolve? Patient: Well, that is an interesting question, for several years ago, simple drugs like amoxicillin used to cure these in a matter of 3 to 4 days. It seems lately that the amoxicillins and even the more expensive, stronger antibiotics may not work, and invariably it takes 2, 3, 4, or even 5 weeks to get rid of these infections. Doctor: Do you have allergic rhinitis? Patient: I do not know. Doctor: The symptoms of allergic rhinitis are itchy eyes, itchy nose and sneezing. Patient: Oh, yes, I have that, particularly in the fall and spring. I call it hayfever. Doctor: Are you aware of any association between these allergies and your sinus infections? Patient: Very much so. When my nose gets congested and I have my hayfever, I very often will get a sinus infection then. Page 1 of 7
Doctor: And how about the association between colds and sinus infections? Patient: Lately, every time I get a cold, it progresses into a sinus infection. A complete medical history and review of systems was obtained. There were no other contributing factors to this individual's current complaints. Doctor: Well, let me now perform an examination. Your ears look normal to me. Your nose shows a significant deviation of your septum to the left side. Your mouth is normal; however, I see some streaking and postnasal discharge in the back of your throat, findings that are often associated with sinus infections. I do not feel any lymph nodes in your neck. I agree with you and your primary care physician. It sounds as if you are having sinus infections. It sounds as though they are becoming increasingly difficult to treat. I would like to order a sinus CT scan. Patient: What is a CT scan? Doctor: CT stands for computerized tomography. Very simply, this is a very special type of x- ray that looks at slices through your nose and paranasal sinuses. Normal and abnormal sinus CT scans can be viewed on a presentation by Dr. Mafee titled "Sinus CT Scans." (Right-click to download.) Very often it helps me document the presence and extent of disease. In any case, it demonstrates the anatomy of your nose and sinuses and is necessary for me to perform surgery, if this becomes required. Patient: While I am waiting for the x-ray, are there things that I can do? Doctor: There really is not much that you can do. If you have an infection, then it needs to be treated with antibiotics. Until we see the x-ray, there is no other therapy I can recommend. Patient: Why is it that the infections have gotten harder and harder to treat, and why is it that they last longer and longer? Doctor: There are small holes that drain each of the sinuses into your nose. Each hole is called an ostium. Two are called ostia. Sometimes they are anatomically narrowed, or sometimes with each infection, as in your case, they become inflamed, and as a result, they scar and narrow further. It is this narrowing which prevents air going into the sinuses and fluids such as infection from coming out. It is for this reason that once infections become recurrent, they become increasingly more difficult to treat, so what has happened to you in the development of your chronic sinusitis is typical of what happens to others. Patient: Do antihistamines help? Doctor: No, antihistamines will sometimes reduce the symptoms of allergic rhinitis. They are not indicated in the treatment of sinusitis, even in cases like yours where the sinusitis is in part caused by the allergy. The antihistamines reduce the normal functions of the nose. They thicken the secretions, and in fact they predispose someone like yourself to sinus infections. Patient: Are nasal steroids of value? Page 2 of 7
Doctor: Nasal steroids are a good treatment for allergic rhinitis. They probably play little role in the management of sinusitis, and in any case, at this late date, once you have developed chronic sinusitis refractory to medical treatment, the steroids are probably of little to no benefit. Two weeks later the patient returns with a sinus CT scan. The doctor is examining the x-rays with the patient. Doctor: Well, these x-rays do show that you have significant infection involving an area called the osteomeatal complex. This is the heart of the drainage system of the nose and paranasal sinuses. Your maxillary sinuses and your ethmoid sinuses are seriously diseased. Your frontal sinuses and sphenoid sinuses are, fortunately, spared. Based on everything that you have told me and confirmed by the x-ray, it is my recommendation that you undergo an operation called endoscopic sinus surgery. That operation will be facilitated by the addition of a septoplasty to improve your nasal breathing. Patient: Could you tell me a little bit more about these surgeries? Doctor: The surgery is performed under general anesthesia. It is performed as an outpatient surgery, which means that you will go home the same day. Once you are asleep, medicine is placed and injected inside your nose. The medicines are decongestants combined with anesthetics. They reduce the bleeding, and, in fact, we do so well today that our typical blood loss is less than a teaspoon. In part because of this anesthetic technique and in part because of the general anesthetic, you will feel nothing throughout the surgery. All of the surgery is performed through the nostril openings. There are no external incisions. Much of the surgery is performed with little telescopes which we call endoscopes. Little microsurgical instruments are then placed inside the nose alongside the endoscopes. The sinus surgery itself is directed at opening the little ostia, that is the little holes that drain and connect your nose with your sinuses. By enlarging these holes, the air flows more naturally into your sinuses. The secretions flow more naturally out of your sinuses. Infections are less likely, and those that do occur, are much more easily treated. Patient: Is there any packing placed inside my nose, and does the surgery hurt? Doctor: In the old days we were very aggressive with packing after nasal surgery. However, today we have new materials, better anesthetics, and better operations. As a result, little to no packing is ever required. Silicone splints are placed alongside the septum. These actually hold the nasal septum in the midline. They assist in healing. They have little straws glued to the side of them and so they allow you to breathe during your recovery; and they are not uncomfortable when removed a week to ten days later. All of the packing that is placed in your nose is absorbable. It does not cause pressure. It causes a minimum of discomfort, and in fact, you will wash it out with nasal irrigation starting about a week after surgery. The day of surgery, the anesthetic in your nose and the grogginess from the general anesthetic are such that patients experience very little discomfort. Usually, the day after surgery people do feel a little uncomfortable and a little stuffy. Most commonly, the discomfort subsides on the following day, patients begin to feel better, and from then on things improve on a daily basis. Patient: When can I return to work? Page 3 of 7
Doctor: It is my recommendation that you take a week off, for while people certainly are well enough to return to work in as few as 3 or 4 days, the body does its best healing when patients are relaxed and asleep. If you return to work, your adrenaline surges, you do not nap, you do not take it easy, and you do not heal as quickly. This is a serious enough illness for you that you are willing to have an operation. I think it is important that you take the week off and do your best to make a full and maximal recovery. Patient: Are there risks and complications to this surgery? Doctor: Yes, there are. All surgeries have risks and potential complications. The risks for nasal surgery are infection, bleeding, scarring and failure to correct the disease. Patient: What exactly do you mean? Doctor: Well, infections can ensue, just like you have with sinusitis. There is an occasional patient who has bleeding, and that may need to be controlled. Occasionally scarring occurs on the inside of your nose, and sometimes this may impair the benefits. However, the most important thing for you to know is that our success rate is about 90%. That means that 10% of patients do not make the recovery they would like to. If that happens, it sometimes becomes necessary to perform additional surgery. However, since most go well, I would prefer not spending more time discussing that at this time. Patient: Are there serious complications? Doctor: Yes, there are. You can die from the anesthetic. Our anesthesiologists are very good. We examine you very carefully, but sometimes there are abnormalities or problems that develop, and very infrequently, serious complications can ensue. You will also note on the x-ray that the sinuses that are diseased lie immediately under your brain and just between your eyes. This means that if there are problems, either because I make a mistake or because there are abnormalities in your anatomy, that there is potential damage to the eye with potential damage to vision, and there is potential damage to the brain with neurologic consequences. Fortunately, these serious complications are uncommon. When they occur, we hope to recognize them and treat them appropriately. Patient: What happens if I do nothing? Doctor: Probably you will continue as you are, some good days, some bad days. You could get better and you could get worse. Just as surgery puts your brain and eye at risk, so does the infection. A story titled "Idaho", written by one of my medical students, Jana Simond, tells of a case where a young woman died from a sinus infection which had progressed into meningitis. Like the surgical complications, this is uncommon. Patient: Will I get black and blue eyes? Doctor: Typically not. All of the surgery is on the inside of your nose, and the black and blue eyes only occur when external surgery is performed, such as a rhinoplasty that would affect your appearance. Page 4 of 7
Patient: Is it possible for me to have the little bump taken off my nose? Doctor: You are asking now about cosmetic surgery. This is an operation that we call a rhinoplasty. Yes, this is a good time to discuss that, for while you are asleep and while we are operating on your nose is an excellent time to perform cosmetic or functional nasal surgery. Patient: Does the insurance company pay for my sinus surgery? Doctor: Typically they do, and in any case, we make sure the surgery is approved, or that we know the answer to that question before going to the operating room. Patient: Would they pay for the rhinoplasty? Doctor: Most insurance companies do not pay for cosmetic surgery. Patient: Can I pay extra to have that performed? Doctor: Yes, you can. Patient: Will it cost as much as if I were having that done alone? Doctor: No, it costs a lot less because you already have the operating room paid for, you already have the preoperative evaluation and postoperative care paid for. You already have the anesthesiologist paid for. If this is something you would like to pursue, we can talk about that and I would be happy to consider and perform the rhinoplasty at the same time. Two weeks later the insurance company authorizes the surgery. It is scheduled two weeks hence. In the preoperative evaluation the patient is counseled to use neither aspirin-containing products nor any medicines that contain blood thinners nor nonsteroidal anti-inflamatory agents. The patient is also counseled to have nothing to eat or drink after midnight the evening preceding surgery. The patient should not have anything to eat or drink the morning of surgery. In the preoperative room, doctor and patient meet again. Doctor: Good morning. Are you ready for your surgery? Patient: Yes, but I am feeling very nervous. Doctor: That is very common, and in fact, I would be worried if you were not a little apprehensive. Let me review: you and I have decided to perform sinus surgery. We are going to straighten your septum, and we had also talked about removing the bump on the top of your nose. Patient: Yes, that is what I would like to have done. Page 5 of 7
Doctor: Well, you just relax. We are going to take good care of you, and I will see you after surgery. The surgery goes well. The physician does meet with the patient in the recovery room, but the patient is sufficiently groggy that little is remembered. The patient is provided medications for discomfort but instructed to take Tylenol and only use the Tylenol with codeine if necessary. The less codeine taken, the better, for codeine can cause an upset stomach and/or constipation, and actually lessens one's ability to tolerate discomfort. On the fourth postoperative day, the patient is seen in the Head and Neck Surgery Clinic. The doctor examines the patient. The surgery has gone well. The patient is having a minimum of discomfort. The patient is instructed to return a week later. At the one-week visit, the nasal splints are removed from the nose. The patient does not feel this, but is amazed at how large the soft silicone splints actually are. At this time, the patient is counseled on the use of nasal irrigation, and instructions are given to use a nasal irrigator twice daily. Three weeks later, the patient returns. Doctor: How are you doing? Patient: I am sorry that I waited so long to have this surgery. My nose is open. I can breathe. The congestion is gone. The pain is gone. I feel like I have a whole new life. Doctor: Have you had any problems? Patient: No. Doctor: Have you had any bleeding? Patient: No. Doctor: How do you like the nasal irrigation? Patient: I actually enjoy it. I wash twice a day. It washes away the nasal mucus and it leaves me with a very refreshed, clean nose, a feeling I have come to like. As a matter of fact, I wanted to ask you, is it okay once the surgery is healed if I continue with the nasal irrigation? Doctor: Yes, it is, and in fact, a large number of my patients continue using a nasal irrigator once or twice a day for the rest of their lives. Patient: Is there anything else I need to know or do? Doctor: Basically not. If you get a cold in the first couple of months, our threshhold for treating with antibiotics is lower than normal. Once you have crossed that magic 3-6 month healing Page 6 of 7
period, you should be as good as, if not better than, whatever is normal for you. However, if problems or questions arise, we would be happy to see you back. Patient: Once again, thank you. I have appreciated the kind care. Doctor: You are very welcome. It is my privilege to provide it. Page 7 of 7