Sinus Surgery - A Complex Procedure

Why Is a Sinus Surgery Needed?

Sinuses are air-filled cavities located in the bones of the face and head. They are lined with mucus to keep them lubricated and flush away the germs; to prevent mucus accumulation, they are drained out, and air flows back into them.

In a significant percentage of the population, these sinuses do not get drained, leading to swollen and inflamed sinuses, followed by congestion (obstruction) in the eyes, nose, and throat, making it difficult to open eyes, breathe and swallow. Some of the reasons for improper drainage of the sinuses are mentioned below:

1. Distorted Sinonasal Anatomy - Most well-known is the nasal septum deviation; others include:

• Deformities in the Chondro Vomeral Junction - Meeting point of the vomer bone with the nasal septal cartilage.

• Concha Bullosa - Folds of the nasal bone get filled with air.

• Maxillary Sinus Septa - Atrophic bone extension of the upper jaw.

• Accessory Ostia - They are openings into the sinus; when more than one is present, they get filled with fiber.

• Presence of Agger Nasi Cells - Agger nasi cells are the most anteriorly placed ethmoidal cells. When observed through an endoscope (an optic fiber with a camera), they appear as swellings along the lateral nasal wall. They are located in the anterior floor of the frontal sinus and therefore are possibly involved in chronic or recurrent frontal sinusitis (inflammation of the frontal sinus).

2. Allergies - In people, when an allergen (foreign body like dust or spore) enters the body, the body identifies it as a danger. It triggers immune reactions resulting in inflammation of the sinuses.

3. Tumors - Tumors in the pituitary gland, like nonfunctional adenomas, prolactinomas, etc., and sinonasal tumors, like squamous cell carcinoma, adenocarcinoma, etc., also cause sinus obstructions.

4. Infections - Bacterial infections (often by Streptococcus pneumoniae or Haemophilus influenzae), viral infections (maybe rhinovirus, influenza, or parainfluenza virus), and last but not least fungal infections (Rhizomucor, Rhizopus, etc.) are often responsible for sinus block.

5. Silent Sinus Syndrome - This is a rare condition where the maxillary sinus collapses without any prior history of any abnormality.

6. Nasal Polyps - These are painless, non-cancerous growths on the lining of the nasal passage resulting in obstruction of airflow and mucus drainage.

7. Skull Base Defects and Lesions - Defects in the skull and lesions of the pterygomaxillary fossa (a fat-filled space in the shape of an inverted pyramid) and petrous apex (a part of the temporal bone) also obstruct sinus drainage.

8. Mucoceles - They are cystic lesions of the salivary glands, thereby increasing pressure on the sinuses.

The conditions mentioned above cause nasal congestion, difficulty breathing, headache, sore throat, and nasal drainage, which lead to poor quality of life and sometimes can be life-threatening. To avoid this, the clinician will first put the patient on maximal medical therapy (MMT), including intranasal corticosteroid sprays, saline irrigation, oral antibiotics, antifungals, mucolytics, etc. If this fails to relieve the symptoms, the next step is sinus surgery.

What Are the Different Types of Sinus Surgeries?

The clinician will suggest a sinus surgery if the symptoms have persisted for more than 12 weeks, as in the case of chronic rhinosinusitis; they will also perform it in acute rhinosinusitis (less than 12 weeks) if simultaneous extracranial and intracranial complications occur. These complications may be:

• Preseptal Cellulitis - Skin and soft tissue infection around the eye, anterior to the orbital septum.

• Orbital Cellulitis - Infection of muscle and fat around the eye.

• Subperiosteal Abscess - An abscess (normally caused due to infection) between the periosteum and cortical plate of the bone.

• Orbital Abscess - An abscess in the orbit of the eye.

• Cavernous Sinus Thrombosis (CST) - Blood clot in the cavernous sinus.

Based on the type of deformation or pathology present, sinus surgery can be divided into the following:

1. Septoplasty - It is an outpatient procedure used to correct nasal septum abnormalities by restructuring the deviated septum.

2. Turbine Reduction - Turbinates (also known as concha) are scroll-like folds of bones in the nasal cavity that divide the nasal chamber into different passages for the air to humidify. In case of any abnormality or infection of these turbinates, a sinus surgery called turbine reduction is performed, which aims to reduce their size, making breathing easier.

3. Functional Rhinoplasty - Done when the septum deviation is more complex and associated with other nasal deformities. The surgeon will resculpt the bone and cartilage for normal functioning.

4. Balloon Sinuplasty - A flexible balloon catheter is inserted into the affected sinus, which is then slowly inflated to open the cavity. The doctor then flushes the mucus and pus with saline. It provides instant relief and is minimally invasive.

5. Functional Endoscopic Sinus Surgery (FESS) - Most popular sinus surgery uses an endoscope to view and remove the infected tissue and bone. There are different types of FESS depending on the location of the pathology, as mentioned below:

• Uncinectomy - Removal of the uncinate (a hook-shaped protuberance of the ethmoid bone).

• Maxillary Antrostomy - Enlargement of the natural ostium (sinus opening).

• Ethmoidectomy - Removal of infected tissue and bone in the ethmoid sinus.

• Sphenoidectomy - Similar to maxillary antrostomy, the opening of the sphenoid sinus is enlarged using the endoscope.

• Frontal Sinusotomy - The natural opening of the frontal sinus is widened, and the infected tissue and bone are removed.

What Are the Complications of Sinus Surgery?

Although with the recent developments in the image-guidance system, complications in many surgeries have been limited, however, a few of them are seen occasionally, which include the following:

• Bleeding.

• Eye injury.

• Brain injury.

• Recurrence of the disease.

Are Sinus Lift Surgery and Sinus Surgery the Same?

Although both may sound similar, they are different procedures with different aims. Sinus surgery is performed in case of an abnormality or pathology. In contrast, sinus lift surgery is a bone augmentation surgery done with implants to the posterior part of the maxilla (upper jaw). This is done before the placement of dental implants in patients with severe atrophic bone loss.

Conclusion

Sinus surgery is a complex procedure. Therefore, different procedures falling in the same vicinity are grouped as sinus surgery based on the part of the bone or tissue involved. Often multidisciplinary providers are involved, ranging from rhinologists, neurosurgeons, ophthalmologists, endocrinologists, oncologists, and pulmonologists to allergy specialists. Post-surgical medical therapy with nasal rinses, corticosteroids, and antibiotics helps to recover soon with minimal recurrence.