Sinus Disease and Treatment

Normal Structure and Function

The human skull has air-filled cavities surrounding the nose which are called sinuses. These empty spaces make the normal head lighter and easier to move, and are essential for vocal resonance.

There are 4 types of sinuses:

1. Maxillary sinuses: a paired group of sinuses, located below the eyes and on either side of the nose. These are usually present at birth, and continue to grow.
2. Ethmoid sinuses: are arranged in a honeycomb pattern and are located between the eyes. These are also present at birth, and continue to grow.
3. Frontal sinus: is located above the eyes in the area of the forehead. It may be single or divided. This sinus usually develops at approximately 7-8 years of age.
4. Sphenoid sinus: is located deep behind the nose in the centre of the skull. It usually develops during adolescence.

The sinuses and the nasal passage itself are lined with a thin layer of tissue called mucosa, which secretes mucous. (The average person actually produces two to four cups of mucous per day).

What is Sinusitis?

Sinusitis is an infection or inflammation of the sinuses. Normally, the sinuses and nose are cleaned by the flow of this mucous and anything that blocks the outflow of this mucous, can lead to sinus pressure, pain, and infection. Colds, allergies or exposure to smoke, can all thicken the mucosa and block the flow of mucous. Bacteria can subsequently grow in the blocked sinus, resulting in sinusitis.

Other conditions can block the normal flow of secretions out of the sinuses and can lead to sinusitis:

• nasal polyps (these are thick swellings of mucosa that enlarge into "clusters")
• anatomical variations of the nose
• adenoid enlargement
• nasal foreign bodies
• nasal trauma
• swimming and diving
• tooth infections
• cleft palate

Clinical Picture

The most common symptom of a sinus infection is pressure and/or pain in the facial region or behind the eyes. This is usually associated with nasal obstruction, green or yellow nasal discharge, post-nasal drainage, and may include a fever. Sinusitis can cause redness and swelling of the skin near the eyes if the infection is severe. Headaches can be caused by sinusitis (and many other conditions).

Although it is difficult to actually see into the sinuses themselves, a nasendoscope (a telescope for looking into the nose) can be used to look at the openings of the sinuses. In some patients pus can actually be seen coming out of the sinuses, which will confirm the diagnosis. Another typical findings of acute sinusitis is a swollen and red nasal cavity.

Diagnostic Investigations

As discussed it is difficult to see into the sinuses, thus doctors use x-rays to help make the diagnosis. A plain x-ray is the simplest form and it shows some of the basic structures in the skull. In most cases to get a good look into the sinuses a CT (CAT) scan is necessary. On CT, bone appears as white, air as black and mucosa or soft tissue as grey. In the healthy state the sinuses are filled with air, and therefore will be totally black. The sinuses are normally lined by a thin layer of tissue called mucosa. This mucosa should not be seen on the CT scan. With chronic sinusitis, there will be thickening on the mucosa and it will show up as an abnormal grey area on the walls of the sinuses. Occasionally blood test and/or cultures from the nose may be taken.

Treatment of Sinus Disease

Medical treatment plan

May consist of:

• Nasal Decongestants: Decongestants should NOT be used for more than 5 days because congestion can actually become worse when using these sprays for a long period of time. If you have high blood pressure or other medical problems contact your family doctor first.
• Salt Water irrigation
• Steroid Nasal Spray: (NASONEX, or RHINOCORT, or BECONASE)

Surgical treatment plan

If sinus infections persist despite maximum medical treatment, then surgery may be necessary. The aim of surgery is to improve the natural drainage system of facial sinuses and to remove any anatomical obstruction or diseased areas which cause recurrent or chronic sinus infection.

What is Functional Endoscopic Sinus Surgery (FESS)?

The use of endoscopes has revolutionised all forms of surgery in the past ten years by providing vision into body spaces with excellent illumination, magnification and "around the corner" views. Endoscopic vision in the nose and sinuses permits more delicate surgical techniques with more precise and thorough removal of diseased tissue and polyps, and a better chance of long-term cure. Diagnosis and post-operative care are also enhanced by the use of endoscopes. Endoscopic sinus surgery is performed through the nostrils and occasionally external incisions. The combination of endoscopic operative techniques, and excellent CAT scans for diagnosis (and as a "road map" for surgery) has markedly improved the results and dramatically lessened the discomfort associated with surgery.

Pre-operative instructions (this does not apply to all patients)

Antibiotics and Prednisone (cortisone) may be required 5-10 days prior to surgery. These help reduce the amount of infected and inflamed tissue in the sinuses and so decrease the bleeding during surgery. Side effects from Prednisone can include headache, itchy skin, cramps, abdominal pain, temporary mood changes, elation or slight depression and insomnia. In general, the longer steroids are taken and the higher the dose used, the greater is the chance that side‑effects may develop. If the drug is only used for a few weeks, most side effects will be mild and temporary. Some patients, however, who need steroids for months or years due to severe medical diseases will almost certainly develop some permanent side‑effects including swelling of the face and neck, skin changes and joint problems.

Dr Becvarovski prescribes steroids infrequently and for as short a duration as possible. Because an increase in blood pressure, blood sugar and stomach acid are not uncommon, you should consult with your family doctor prior to starting the steroid if you have hypertension, diabetes or peptic ulcers.

• DO NOT TAKE ASPIRIN OR ASPIRIN RELATED MEDICATION IN THE 14 DAYS PRIOR TO SURGERY (NB: PANADOL, PANADEINE and PANADEINE FORTE can be taken) - see Back Page– Medications to Avoid
• DO NOT CONSUME ALCOHOL 10 DAYS PRIOR TO SURGERY
• YOU MUST BRING YOUR SINUS CT SCANS TO THE HOSPITAL (NO X-RAY means NO OPERATION)
• You must be adequately fasted on admission to hospital. See pre-admission details.

The Procedure

The operation is performed under a general anaesthetic and requires an overnight stay in hospital and 7-14 day's absence from school or work. The operation is performed using a telescope as this gives excellent visualisation of the area. Protection of the brain, eye and blood vessels, all in close proximity, is of paramount importance.

Post operative Care

While in hospital

Nasal packing may be required, this depends on the amount of bleeding. If used, it will be removed the afternoon of surgery or next morning. Post-operative pain may require an injection but it is usually only mild by the next day. The degree of pain and headache is variable and unpredictable. Blood will be swallowed after the operation and this may cause some nausea and sometimes vomiting of old blood in the first day after surgery. Most patients will be discharged from hospital on the first or second post-operative day.

After discharge

May consist of:

• Nasal douching
• Nasal ointment
• Antibiotics

• Seven days are required off work. No heavy lifting or straining for 2 weeks after discharge. (Sitting in a chair/bed for the first 3-4 days is recommended, then short walks after this)
• Avoid running hot water onto your face during showers for a prolonged period of time.
• Avoid hot drinks in the first few days (Stick to a cool diet).
• PANADOL OR PANADEINE CAN BE TAKEN FOR PAIN.
• DO NOT TAKE ASPIRIN OR ASPIRIN RELATED MEDICATION FOR 3 WEEKS FOLLOWING SURGERY (see Back Page– Medications to Avoid)

What are the risks of Endoscopic Sinus Surgery?

The risks are the same as those for traditional sinus surgery.

1. Severe bleeding (and possible blood transfusion)- can occur suddenly up to two to three weeks after operation, sometimes from infection, overheating, over activity or excessive nose blowing - RARE.
2. Damage to Vision - The bone which separates the eyeball from the sinuses is quite thin and it may be best to leave some unhealthy sinus lining attached rather than risk damage. Visual loss is EXTREMELY RARE.
3. Double Vision -from damage to eye muscles. Can occur, usually temporarily, especially if an external incision is required - EXTREMELY RARE.
4. Leak of Cerebrospinal Fluid (CSF) - The bone separating the brain from the sinuses is very thin in some places and a leak of fluid from around the brain (CSF) can occur. This leak can be plugged at the same time or at a later operation without any ill effects - VERY RARE.
5. Watery Eye - The tear ducts run through the front of the sinuses and can be traumatised at surgery. The watery eye may settle without treatment or need to be corrected by surgery - VERY RARE. NB: The eyes will usually water while nasal packing is in place.
6. Loss of Sense of Smell - VERY RARE. (NB: If the sense of smell is poor before surgery, it will not necessarily be improved by surgery).
7. Failure to Cure, or Recurrence of Symptoms after Operation – MORE COMMON. The aims of surgery are to remove disease such as polyps and infection, and obtain good ventilation and drainage of the sinuses. Symptoms may recur if unhealthy lining regenerates during healing. Antibiotics and steroid tablets are often used to try and prevent this. Rest and avoidance of chills and infections during the first three weeks are very important. Extra Vitamin C and Vitamin E during healing is recommended. Sinus surgery facilitates ventilation and drainage of the sinuses but ultimately the body healing itself determines whether a cure will result. If the sense of smell is poor it will not necessarily be improved by surgery. The degree of improvement or cure varies from case to case depending on factors such as previous surgery, extent of disease, degree of allergy and resistance to infection.
8. General anaesthesia: There the usual risks with any general anaesthesia - VERY RARE.

Medications to Avoid Before and After Surgery

All medications that you are currently taking should be discussed with your surgeon prior to your operation.

There are two groups of drugs which are very important to avoid prior to your operation. These are Aspirin containing medications, and a family of drugs called 'Non Steroidal Anti Inflammatory Drugs' (NSAID's). Both of these drugs affect the ability of your blood to clot, and so may predispose to post operative bleeding and complications.

Please make sure to check this list carefully and avoid ALL these medications for two weeks prior to surgery, and for three weeks after surgery. If you have any questions regarding this or are taking any of these medications for specific conditions, please contact your general practitioner and notify this office.

Some herbal supplements (such as Garlic) may increase the risk of bleeding. Thus ALL herbal supplements should also be avoided for the above time periods specified.