Sinus Surgery Patient Information

Anh Q. Truong, MD

Bellevue ENT

1231 116th Avenue NE, Suite 915

Bellevue, WA 98004

Phone: (425) 454 - 3938

What are the indications for minimally invasive functional endoscopic sinus surgery (FESS)?

Sinus infections can have a significant impact on quality of life with loss of productivity at work and school. The majority of patients with sinus infections are successfully treated with conservative methods including rest, topical therapy, and oral medications. In general, the decision to proceed with sinus surgery is one that the patient and ENT surgeon make together given the complexity of various types of sinus infections and their presentation to the individual patient.

A small subset of patients who develop severe complications related to sinus infection or patients that do not respond to conservative therapy with a quality-of-life impairment may benefit from sinus surgery. Sinus surgery is usually reserved for patients who are symptomatic and do not respond to medical therapy (chronic sinusitis) or for patients who develop frequent recurrent infections despite medical treatment (recurrent acute sinusitis). Other indications include invasive fungal sinusitis, nasal polyps, sinus and nasal tumors, mucoceles, and sinus infections affecting pulmonary conditions such as asthma, bronchitis, pneumonia and cystic fibrosis. In rare cases of severe orbital or intracranial complications, sinus surgery may be the first line of treatment in addition to medical management.

What is functional endoscopic sinus surgery?

Functional endoscopic sinus surgery (FESS) is a minimally invasive surgical procedure designed to open up the natural drainage pathways of the paranasal sinuses for better mucous clearance and aeration of the sinuses. With wider openings, topical treatments are more feasible and reduce the need for oral and systemic antibiotics.

Functional endoscopic sinus surgery is performed through the nostrils using a fiberoptic endoscope and endoscopic instruments. There is typically NO external incision and no external facial changes are anticipated. Depending on your surgery center and the extent of your surgery, your surgeon may use neuronavigation to achieve a safer and more thorough surgery.

Schematic of endoscopic sinus surgery. Source: Krames Patient Education – Endoscopic Sinus Surgery

What should I expect before surgery?

• 1. To prepare for your surgery, your physician may prescribe preoperative medications to optimize the condition of your sinuses for surgery. The medications may include antibiotics and/or oral steroids. Be sure to start any preoperative medications on the appropriate day and adhere to the direction.

  2. DO NOT TAKE THE FOLLOWING MEDICATIONS FOR AT LEAST 14 DAYS PRIOR TO SURGERY: aspirin, ibuprofen (Motrin/Advil), naproxen (Aleve), other non-steroidal anti-inflammatories (NSAIDS), vitamin E (multivitamin is OK), gingko biloba, garlic (tablets), and ginseng. These medications can thin the blood and create excessive bleeding. Tylenol is safe and may be taken any time up to the day of surgery. St. John's wort should also be avoided for 2 weeks prior to surgery because of possible interactions with anesthesia medications. If you take the blood thinner Coumadin or Plavix, you must discuss this with your surgeon so the medication can be discontinued before surgery and restarted appropriately.

  3. If you smoke, you must stop smoking for at least three weeks prior to surgery, and at least four weeks after surgery. Smoking can contribute to scarring, poor healing, and failure of the operation. Your primary care physician can direct you to resources for smoking cessation.

  4. While our office will make every attempt to keep your primary care physician informed before and after your surgery, it is important that you personally inform him/her that you are planning to have sinus surgery. If you have underlying medical conditions, your primary care physician may help to clear you medically for surgery. Most of the necessary pre-operative testing will be performed at Bellevue ENT during your preoperative visit. This takes place approximately 1 week prior to your surgery if needed.

  5. Due to the frequently changing operating room schedule, the surgery center will usually call you one business day before your surgery date to inform you of your surgery time. You are usually expected to arrive two hours prior to your surgery to check in.

What should I expect during surgery?

Your surgical team will include your surgeon, an anesthesiologist, a scrub nurse, a circulating nurse, and additional supporting staffs dedicated to ensuring that your surgery is safe. Sinus surgery is typically performed under general anesthesia and will usually last about 1-3 hours. However, this may vary depending on each patient. The extent of your sinus surgery depends on which specific sinus is causing you problems. In addition, a septoplasty may be performed if your nasal septum is significantly crooked (deviated septum) and inhibits access to your sinuses.

Typically, nasal packing is not placed with endoscopic sinus surgery unless significantly bleeding is expected after surgery. Your surgeon may place a temporary stent or a dissolvable implant if you have severe sinus infections and/or nasal polyps. If a septoplasty is performed, a thin internal septal splint may be placed temporarily and will be removed about 5-7 days after surgery.

Figure 5. A patient with chronic sinusitis not responsive to antibiotics, nasal polyposis, a septal deviation (not shown), and bilateral concha bullosa. The right concha bullosa is also full with mucous on the CT scan.

Figure 6. The nasal polyps are partially removed and the concha bullosa is opened with the finding of thick mucopurulent mucus (left) in the patient above. The maxillary sinus is opened with thick mucopurulent mucus.

What should I expect after surgery?

• 1. After your surgery, you will spend approximately 1-2 hours in the recovery area. Approximately 1 hour after you arrive in the recovery area, a family member or friend should be able to visit with you. Most patients feel well enough to go home the same day. You should not drive yourself home and you need to arrange for transportation prior to surgery.

  2. You can expect mild bleeding for 1-2 days after surgery. Pain can generally be controlled with over the counter Tylenol; however, narcotic (prescription) medication will be provided for additional control if needed.

  3. You may eat a regular diet.

  4. You will have return visits to the ENT clinic at approximately 1, 3, and 6 weeks after surgery. At your first post-operative visit, the doctor will examine your sinuses with an endoscope and may clean your sinuses of dried blood. There may be some mild discomfort and we recommend taking a dose of pain medication about 45 minutes to one hour before this visit (as long as someone can accompany you on your visit). Please write down any questions you may have so that we can answer them at your appointment.

  5. You should plan on taking one week off from work and ideally have a half-day planned for your first day back.

  6. Please see the post-operative instructions for additional details.

What are the risks of endoscopic sinus surgery?

As with any surgical procedure, endoscopic sinus surgery has associated risks. With meticulous planning and appropriate precautions, complications from sinus surgery are very rare. Although the chance of a complication occurring is extremely rare, it is important that you understand the potential complications and ask your surgeon about any concerns you may have. These risks may include:

• • Bleeding: Most sinus surgery involves some degree of blood loss, which is generally well tolerated. Rarely, significant bleeding may require termination of the procedure. Although most patients do not require nasal packing, a few patients will require a small nasal pack or tissue spacer to be placed. This is removed at the first post-operative visit. Blood transfusion is rarely necessary and is given only in an emergency. Uncommonly, patients may have bleeding in the early post-operative period that could require nasal packing.

  • Recurrence of disease: Although endoscopic sinus surgery provides symptomatic relief for the vast majority of patients, surgery is not a cure for sinusitis. It would be expected that the frequency and severity of your sinus infections will improve and your requirements for medications should be lessened. In some instances, additional "touch-up" or revision surgery may be necessary to optimize your surgical outcome.

  • Spinal fluid leak: Because the sinuses are located near the brain, there is a rare chance of creating a leak of spinal fluid (the fluid lining the brain) or injuring the brain. Should the rare complication of a spinal fluid leak occur, it may create a potential pathway for infection, which could result in meningitis. If a spinal fluid leak were to occur, it would require surgical closure and hospitalization.

  • Visual problems: Visual loss has been reported after sinus surgery due to injury to the eye or optic nerve. The potential for recovery in such cases is not good. Fortunately, such a complication is extremely rare. Injury to the eye muscles may result in double vision. Persistent tearing of the eye is another possible complication. Tearing problems usually resolve on their own but occasionally require additional surgery.

  • Other risks: Other uncommon risks of surgery include alteration of sense of smell or taste; persistence and/or worsening of sinus symptoms and facial pain; change in the resonance or quality of the voice; and swelling or bruising of the area around the eye.

What restrictions will I have during the postoperative recovery period?

• 1. DO NOT BLOW YOUR NOSE for the first week after surgery. You may sniff back. If you need to sneeze, do not suppress it but instead sneeze with your mouth open. After 1 week, you may blow your nose gently.

  2. No strenuous activity for one week after surgery. No straining or lifting more than 15 lbs. You should not bend over at the waist to pick things up. Instead, bend at the knees with your head up. Light walking and normal household activities are acceptable immediately after surgery. You may resume exercise at 50% intensity after one week, and full intensity at two weeks. You may drive the day after surgery if you are not requiring narcotic pain medication.

  3. If you are taking antibiotics and experience stomach upset, active culture yogurt or acidophilus tablets (available at health food stores) on a daily basis may help. If you develop diarrhea, stop your antibiotics and contact our office. Persistent diarrhea may require further medical evaluation.

  4. You should plan on taking one week off from work.

  5. Do not fly without your doctor’s clearance for 10 days after surgery.

Your surgeon is committed to providing you with the highest level of care in a comfortable and caring environment. We want you to have all of your questions answered and provide you with a complete understanding of your sinus condition and treatment plan. Please feel free to ask questions about any aspect of your care. Learn more about sinus infection, nasal polyposis, or post-operative care for sinus surgery.