What are the benefits of endoscopic sinus surgery?
The goal of endoscopic sinus surgery is to improve the drainage of the sinuses and prevent mucus from building up in these chambers. When secretions accumulate in a blocked off sinus, they may become infected with bacteria and result in a flare up of sinus symptoms. By widening the natural drainage pathways of the sinuses, surgery helps to decrease the frequency, severity, and duration of infections.
It is important to understand that surgery is not a cure for sinusitis. In most patients with sinusitis, the lining of the nose and sinuses (the mucosa) overreacts to irritants, swells, and causes accumulation of mucus. Sinus surgery does not directly treat this over-reactive lining, but instead drains the sinuses and allows the mucosa to improve on its own. However, due to allergy or irritant stimulation, the lining may remain inflamed after surgery. This is typically the case, so medications like nasal sprays and antihistamines remain essential after surgery.
Opening the sinus cavities more widely allows the spray medications to get into the sinuses and directly act on all of the mucosa. It also promotes drainage of mucus so that irritants are removed from the nose. Surgery, therefore, acts with medications to improve the lining and keep the sinuses healthy. It is an adjunct to, not a replacement for, proper medical management.
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What are the risks?
Surgery, like all events in life, has some risks. Your surgeon has spent years developing his technique to minimize these risks and also teaches others how to do the same. Nevertheless, you should be aware of the potential risks of the surgery so you can make an informed decision. All surgeries carry with them the risks of bleeding, infection, and pain. The risk of bleeding is increased by certain medications so you should review all medications (prescription, over-the-counter, and herbal) with your physician prior to surgery.
Aspirin must be stopped at least 10 days prior to surgery and other anti-inflammatory medications such as ibuprofen (Motrin, Advil) must be stopped at least four days prior to surgery. Rarely, excessive bleeding requires the use of nasal packing or may even force termination of the procedure. In extremely rare cases, blood transfusion may be required. If a transfusion is necessary, it carries the risk of transfusion reaction as well transmission of blood-borne disease.
Taking antibiotics after the procedure will minimize the risk of infection. The length of antibiotic treatment is individualized based on endoscopic findings but usually lasts two to four weeks. Most patients’ pain is relieved by extra strength acetaminophen (for example, Tylenol) or a mild narcotic and acetaminophen combination. You will receive a prescription for sufficient pain medicine after your surgery. Some scar tissue develops after any surgery, but if it is excessive it may obstruct the newly opened sinuses. You should expect to visit your surgeon multiple times during the initial post-operative period. This post-operative care is critical to the success of the surgery and usually requires visits every week or every other week for four to six weeks. During these visits, your nose and sinuses will be thoroughly examined to be sure it is healing properly and that excessive scarring is not developing. Sometimes it is necessary to remove a small amount of scar tissue under local anesthesia.
Some temporary swelling or bruising around the eye may occur after surgery. Tears may run from the eye for a few days after surgery. This is usually temporary but in rare cases may persist. If so, this condition can typically be corrected with minor surgery.
In some cases it is necessary to straighten the nasal septum in order to gain access to the sinuses or to improve breathing through the nose. This procedure, called a septoplasty, carries with it the additional risks of a permanent hole in the septum (septal perforation). Rarely septoplasty can change the appearance of the nose or cause permanent numbness of the front top teeth. Nasal surgery, in rare cases, can also lead to loss of the sense of smell.
Lack of improvement or even worsening of the underlying condition and the need for re-operation are other risks inherent with any surgery. Surgery also carries with it risks of anesthesia. Endoscopic sinus surgery can usually be performed under either local or general anesthesia. You should discuss your anesthesia preferences with your surgeon in order to determine what is best for you. You will also have an opportunity to discuss the risks and benefits of each form of anesthesia with an anesthesiologist.
Are There Alternatives For Endoscopic Surgery?
Continuing with medical therapy alone and avoiding surgery is always an alternative. Additionally, other types of sinus surgeries exist and you may wish to speak with your surgeon about them. As with any surgery, you should feel comfortable seeking a second opinion from another surgeon.
What should I expect after surgery?
Healing - The majority of the healing in your nose will take place over the next 4-6 weeks. In patients with nasal polyps and severe mucosal hyperreactivity (over-reactive nasal and sinus lining), the process can take much longer. During this time, you will want to keep your nose out of dusty or smoky environments as much as possible. This includes tobacco smoke.
Medications - Following your surgery you will receive prescriptions for a number of medications. Typically these include pain medicine and antibiotics. In some cases, patients will be on steroid pills after the surgery. It is essential that the prescriptions be filled promptly and the medications taken as directed. These medications are essential components of your care, promoting rapid and correct healing. Failure to take them properly can lead to post-operative infection and scarring within your sinuses.
The medications will be adjusted based on the progress of the healing. This will be assessed by examining your nose during your visits following surgery. Some medications will be continued, some will be stopped, and other new ones will be started. Do not stop the medications on your own without speaking to your physician. You may restart your nasal steroid sprays one week after the surgery. If you have a question, please contact the office. We want to make sure the healing progresses appropriately and that the surgery is a success.
Irrigating - Crusting of blood and mucus can slow the healing process. In order to keep your nose moist and prevent the crusting, you should use saline (salt-water) nasal irrigation for at least two weeks following surgery. A simple system to use is NeilMed’s Sinus Rinse, which can be purchased or ordered over the counter at many pharmacies.
For the first five days following surgery, you should irrigate your nose two to three times a day. Try to irrigate as forcefully as you can to clear out as much of the dried blood and mucus as possible. If your nose feels dry or stuffy between irrigations, you can also use saline nasal spray. Try to keep the inside of your nose as moist as possible. The more you use the saline irrigation and spray, the easier the postoperative visits will go.
Fatigue - Fatigue for two or three days following the surgery is common. You will want to take it easy for a few days following surgery. You should also avoid strenuous physical activity for a few days. Moderate activity (like going for a walk) is acceptable.
Work - Most individuals return to work within a week following surgery. Some return earlier, some later. Plan to be out for a week and return as soon as you feel up to it.
Travel - Many of our patients come from some distance. We prefer you stay in the local area overnight following the surgery. If necessary, you may travel by air 48 hours after the surgery.
Post-operative visits - The care of your sinuses does not end when the surgery is completed. Frequent postoperative visits over the course of four to six weeks are another important component of your treatment. During these visits, your physician will examine your nose with a nasal telescope (similar to before your surgery) and ensure the healing is progressing. Debridement (removal of dried blood and mucus) may also be necessary while the nose regains its ability to care for itself. In some cases, small revisions and adjustments of the healing under local anesthesia are necessary to ensure scar tissue does not obstruct the sinuses.
Since your nose will be tender for a few weeks following the surgery, we recommend that you take one or two tablets of the pain medicine about 30 minutes prior to your visit. Because the medicine contains a narcotic, you will need to have someone drive you home after the visit. Taking the medicine before the visit allows most patients to undergo the exams with minimal discomfort.
What are a few things I should know?
Bleeding - Oozing from the nose is common for 24–48 hours following surgery. It may occur for 12–24 hours after each post-operative visit also. You should probably put an old pillowcase on your pillow or put a towel over it. Additionally, you may want to sleep with your head elevated on an extra pillow to minimize the oozing. After a couple of days, the discharge from your nose may turn maroon or dark brown. This change is due to old blood and is normal. It does not mean that the nose or sinuses are infected.
Occasionally, persistent bleeding from the nose can develop. If this occurs, sit upright and breathe through your nose for 5–10 minutes. This should relieve most bleeding. If it does not, or if the bleeding is heavy, contact our office.
Nausea - Nausea and even vomiting following general anesthesia are not uncommon. They can occur after local anesthesia too, but less often. The nausea usually fades after about 12–24 hours. Try to sip liquids to avoid dehydration during these periods. If the nausea is severe notify our office.
Pain - Some discomfort following the procedure is to be expected but usually is not especially severe. Use the pain medicine as needed. As soon as you feel ready, try to switch to an over the counter pain medicine like extra-strength acetaminophen (for example, Tylenol). For the first two to three weeks after surgery, do not use medications that contain aspirin, ibuprofen, or other anti-inflammatory compounds as these promote bleeding. Medications containing acetaminophen are best during this stage of healing. Remember to take your prescription pain medicine prior to your first couple of post-operative visits.
Sometimes after anesthesia, your muscles may ache all over like you have lifted weights or strained muscles, particularly in the first day or two after surgery. Take over the counter pain medicine for this and stretch your muscles—it will subside.
What are the "don'ts?"
Nose blowing - You may sniff (even vigorously) if you feel you need to clear your nose. Realize that the interior of the nose will be swollen for two to three days and may not clear—even with the most forceful attempts. Blowing your nose too early in the healing process can be dangerous. You may begin to blow your nose lightly three days following the surgery.
Bending, lifting, straining - Placing your head below your waist (like tying your shoes), lifting anything over 10 pounds (including children) and straining will all increase the risk of bleeding. You should avoid these activities for one full week following surgery.
Swimming - While the nose heals, pool and lake water can inflame or infect it. You should not swim for at least four weeks following surgery.
When should I call a doctor?
Promptly report the following symptoms to your doctor:
- Severe headache accompanied by nausea, vomiting, or unusual change in behavior
- Any change in vision, including blurring or double vision
- Light causing pain in your eyes
- Swelling or bruising around the eyes
- Fever (100.6 degrees or higher)
- Stiffening neck
- Diarrhea
- New rashes
- Clear, watery discharge from your nose