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The ear, nose, and throat specialist will
prescribe many medications (antibiotics, decongestants, nasal steroid
sprays, antihistamines) and procedures (flushing) for treating acute
sinusitis. There are occasions when physician and patient find that the
infections are recurrent and/or non-responsive to the medication. When
this occurs, surgery to enlarge the openings that drain the sinuses is
an option.
A recommendation for sinus surgery in the early 20th
century would easily alarm the patient. In that era, the surgeon would
have to perform an invasive procedure, reaching the sinuses by entering
through the cheek area, often resulting in scarring and possible
disfigurement. Today, these concerns have been eradicated with the
latest advances in medicine. A trained surgeon can now treat sinusitis
with minimal discomfort, a brief convalescence, and few complications.
A clinical history of the patient will be created before any surgery
is performed. A careful diagnostic workup is necessary to identify the
underlying cause of acute or chronic sinusitis, which is often found in
the anterior ethmoid area, where the maxillary and frontal sinuses
connect with the nose. This may necessitate a sinus computed tomography
(CT) scan (without contrast), nasal physiology (rhinomanometry and nasal
cytology), smell testing, and selected blood tests to determine an
operative strategy. Note: Sinus X–rays have limited utility in the
diagnosis of acute sinusitis and are of no value in the evaluation of
chronic sinusitis.
Sinus Surgical Options Include:
Functional endoscopic sinus surgery (FESS):
Developed in the 1950s, the nasal endoscope has revolutionized
sinusitis surgery. In the past, the surgical strategy was to remove
all sinus mucosa from the major sinuses. The use of an endoscope is
linked to the theory that the best way to obtain normal healthy
sinuses is to open the natural pathways to the sinuses. Once an
improved drainage system is achieved, the diseased sinus mucosa has
an opportunity to return to normal.
FESS involves the
insertion of the endoscope, a very thin fiber-optic tube, into the
nose for a direct visual examination of the openings into the
sinuses. With state of the art micro-telescopes and instruments,
abnormal and obstructive tissues are then removed. In the majority
of cases, the surgical procedure is performed entirely through the
nostrils, leaving no external scars. There is little swelling and
only mild discomfort.
The advantage of the procedure is that
the surgery is less extensive, there is often less removal of normal
tissues, and can frequently be performed on an outpatient basis.
After the operation, the patient will sometimes have nasal packing.
Ten days after the procedure, nasal irrigation may be recommended to
prevent crusting.
Image guided surgery: The
sinuses are physically close to the brain, the eye, and major
arteries, always areas of concern when a fiber optic tube is
inserted into the sinus region. The growing use of a new technology,
image guided endoscopic surgery, is alleviating that concern. This
type of surgery may be recommended for severe forms of chronic
sinusitis, in cases when previous sinus surgery has altered
anatomical landmarks, or where a patient’s sinus anatomy is very
unusual, making typical surgery difficult.
Image guidance is
a near-three-dimensional mapping system that combines computed
tomography (CT) scans and real-time information about the exact
position of surgical instruments using infrared signals. In this
way, surgeons can navigate their surgical instruments through
complex sinus passages and provide surgical relief more precisely.
Image guidance uses some of the same stealth principles used by the
United States armed forces to guide bombs to their target.
Caldwell Luc operation:Another option is the
Caldwell-Luc operation, which relieves chronic sinusitis by
improving the drainage of the maxillary sinus, one of the cavities
beneath the eye. The maxillary sinus is entered through the upper
jaw above one of the second molar teeth. A “window” is created to
connect the maxillary sinus with the nose, thus improving drainage.
The operation is named after American physician George Caldwell and
French laryngologist Henry Luc and is most often performed when a
malignancy is present in the sinus cavity.
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