Endoscopic Sinus Surgery

This article was first published on Sinus Doctor

What is endoscopic sinus surgery?

Functional Endoscopic sinus surgery is a nose and sinus surgery performed under endoscopic guidance. During endoscopic sinus surgery, a 4mm endoscope is inserted through the front of the nose to visualise the interior of the nose and sinuses. The endoscope is connected to a camera, and a magnified vision of the nose and sinuses is seen on a surgical monitor. A magnified image allows for the precise removal of tissues. The resolution of these monitors range from high definition to 4K allowing for better contrast and delineation of healthy from unhealthy tissue and also helps in avoiding injury to crucial structures. Necessary instruments are inserted alongside the endoscope to perform the surgical procedure. Endoscopic sinus surgery is an advancement to conventional sinus surgery, where an external incision was required to complete the surgical procedure. Functional Endoscopic sinus surgery is an incision-free and scar-free procedure where no marks are seen on the outer skin.

Endoscopic sinus surgery is commonly indicated for patients having chronic sinusitis. In chronic sinusitis, the skin (nasal mucosal) lining of the nose and sinuses become inflamed and thickened due to various reasons. As a result, the sinus drainage pathways get blocked from this thickened inflamed mucosal lining, causing stasis of mucus, a thin slimy fluid produced inside the sinuses. The blocked mucus turns into pus as bacteria start depositing in it as mucus is rich in nutrients.

Patients having chronic sinusitis experience nose block, facial heaviness, headache, postnasal discharge and nose bleeding. These patients are tried with medications. If the relief is incomplete despite using adequate medication or recurrence of symptoms once the medication is stopped, Functional endoscopic sinus surgery is recommended.

What can we expect after Endoscopic Sinus Surgery?

Functional Endoscopic sinus surgery is usually performed under general anaesthesia. However, in patients having co-morbidities and at high risk for general anaesthesia, endoscopic sinus surgery is done under local anaesthesia. The duration of endoscopic sinus surgery ranges from 45 minutes to 2 hours.

After Functional Endoscopic Sinus Surgery, nasal packing or nasal balloons are placed inside both nostrils. We rarely pack the nose after endoscopic sinus surgery at our Sinus Doctor centre because of the special techniques and advanced equipment we use during surgery. I can say that out of every 500 endoscopic sinus surgeries done at my centre, I pack one persons nose.After Functional Endoscopic Sinus Surgery, nasal packing or nasal balloons are placed inside both nostrils. We rarely pack the nose after endoscopic sinus surgery at our Sinus Doctor centre because of the special techniques and advanced equipment we use during surgery. 

I can say that out of every 500 endoscopic sinus surgeries done at my centre, I pack one persons nose.

We usually use nasal rapid rhino balloons from smith and nephew as they are much more comfortable for patients in comparison to conventional nose packing. However, the pricing is on the higher side. In addition, when nose packing is done, the patient cannot breathe through his nose and will have to breathe through his mouth.

Therefore, the patient will experience some discomfort, nasal congestion and pressure when packing is done.

• The patient is kept under observation in a step-down unit after surgery for six hours. His vitals (Pulse, Blood pressure) will be monitored in the step-down unit. In addition, periodic headlight examination of the front of the nose and back of the throat is done to check for any active bleeding. The head end of the bed on which the patient is lying down may be slightly elevated.
• The patient will experience mild sedation after endoscopic sinus surgery in the step-down unit. It will take some time for the anaesthesia to wear off completely and for the patient to come back to his full senses.
• The patient may experience mild discomfort in the throat because of the anaesthesia intubation. However, this discomfort settles within a day once the patient starts eating and drinking six hours after surgery completion.
• Continuous mild bloody discharge from the front of the nose and back of the nose is very common after endoscopic sinus surgery. Gentle dabbing with wet cotton is advised to absorb the discharge.
• Although some nose block relief is felt immediately after surgery (when no nasal packing is done), nasal congestion begins and progresses in the immediate post-operative period because of the temporary swelling of nose and sinus tissues from surgery. Some relief in nasal congestion can be felt with saline nasal douching advised as a treatment after surgery. Better relief in nasal congestion is felt after endoscopy nose cleaning is done ten days after surgery, and from there on, nasal congestion improves dramatically. Complete relief of nose block takes thirty to sixty days. Mild pain, headache, facial pressure and discomfort around the nose and eyes are commonly felt after endoscopic sinus surgery. Pain medication works very well for these issues.

What is the recovery time from Endoscopic Sinus Surgery?

After Functional Endoscopic Sinus Surgery, the patient is monitored in a step-down unit for six hours. After six hours patient is shifted to his in-patient room, he will be allowed to take fluids and soft food once he is moved to the room. The patient will be kept under admission overnight. He will be discharged the next day after the operating surgeons team examines him to ensure no active bleeding from the front or back of the nose. Once discharged, the patient can get back to his desk work immediately. No bed rest is required after discharge.

After discharge, the patient is advised to follow these instructions – Post-operative care

• Avoid cold diets and allergy-inducing foods. All other healthy home-cooked foods can be consumed. Avoid alcohol consumption and smoking. Reduce caffeine intake.

• In case you undergo surgery in dry seasons like winter, a humidifier in the nose
• Regularly take antibiotics, antihistamine and pain killer medication as advised in your discharge summary.
• Use nasal saline wash two to four times a day as advised by your doctor. Please keep in mind that watery discharge from the front of the nose a few hours after a nasal saline wash is very common.

• Nasal steroid spray medication, if advised, must be sprayed in both nostrils twice daily, half an hour after nasal saline wash. The nasal spray must be administered by holding the spray on the bottle’s nozzle in a diagonal direction inside the nose, pointing towards the inner corner of the same side eye. This position can easily be achieved using the right hand while spraying in the left nostril and the left hand while spraying in the right nostril.
• Avoid blowing your nose and forcibly clearing your nose. Nasal congestion is very common after functional endoscopic sinus surgery as a result of tissue swelling from surgery. This tissue swelling is very much a part of the natural healing process of your body. Therefore, blowing your nose or forcibly pulling back will not help in clearing the nose. In addition, you may experience severe nose bleeding as a result of this exercise.
• Avoid nose picking and trying removing any material from the inside of the nose. Suppose your endoscopic sinus surgery is paired with septoplasty, i.e., correction of a deviated septum. In that case, sutures may be placed in the front part of the nose to close the incision site. Finger manipulation can hamper healing.

• Avoid strenuous activities such as high-intensity exercise, weight training and heavy lifting. Also, avoid bending and lifting more than 5kgs weight. Short walks and household works can be performed after discharge.
• Avoid activities like flying and swimming for at least 20 days after surgery. Activities like SCUBA diving should be avoided for a month.

The patient is advised to immediately call his operating surgeons team if he experiences any of the following

1. Fever with temperature more than 101 degrees F
2. Altered vision or worsening headache or facial pain not relieving with prescribed pain medication
3. Bruising on the face
4. Continuous nose bleeding from front or back of the nose
5. Nausea, vomiting, or difficulty bending the neck forward

Follow up of Endoscopic Sinus Surgery?

Following the functional endoscopic sinus surgery procedure, your operating surgeon will advise a review visit in his operation theatre after ten days for endoscopy nose cleaning. Your nose will be locally anaesthetised during this visit by gently packing your nasal cavity with nose packs. He will examine your nose and sinuses with an endoscope. Any crusting which has formed in your nose from surgery and nasal discharge will be removed. This procedure will not take more than half an hour. Once this procedure is completed, you will be kept under observation for an hour and later discharged.

You will be asked to come for two review visits in the outpatient department twice after your first visit ten days apart. Your ENT doctor will examine your nose with a headlight or an endoscope during both these review visits. Any small crusts, if persisting, will be removed.

The subsequent review visits will depend upon your nose and sinus post-op status. You will be advised medication during each review visit which should be used as instructed. If you are experiencing any adverse events after using the medicine, please get in touch with your operating surgeons team.

What are the risks & complications of Endoscopic Sinus Surgery?

Functional endoscopic sinus surgery, like any other surgery, carries few risks. When endoscopic sinussurgery is done by an ENT surgeon specially trained in it using high-resolution endoscopes and monitors, the chances of risks drops drastically. The usage of sinus navigation equipment specially available at our Sinus Doctor centre, which acts as a GPS, adds a further layer of security, allowing complete removal of disease while causing no damage to critical structures. 

Choosing a high-volume nose and sinus surgery operating centre like Sinus Doctor centre, where we operate on more than 1200 simple to advanced sinus surgeries every year, is always advisable. We have developed multiple systems, safety checklists, and our staff at all levels are trained to handle chronic sinusitis patients.

The very rarely occurring risks/ complications involved in sinus surgery are

• Bleeding: There will be some blood loss in every endoscopic sinus surgery, which is well tolerated. Very rarely, there may be profuse uncontrollable bleeding forcing the operating surgeon to pack the nose with nasal packs.
• CSF leak: The nose is separated by a papery thin bone (cribriform plate) from the brain and CSF fluid cushion surrounding it. When an existing breach in the cribriform plate opens up during endoscopic sinus surgery, or a breach happens during surgery, the brain fluid can leak into the nose. Most of these leaks can be recognised during the surgery and sealed appropriately. Rarely, CSF leaks may present after discharge as fluid leaking from one side of the nose or can present as meningitis when the patient presents with excruciating headache, vomitings and loss of neck flexibility
• Vision problems: a thin sheet of bone called lamina papyracea separates the nose from the eyeball socket present immediately next to it. Very rarely, vision loss can occur when the optic nerve is damaged. Sometimes, the muscles responsible for eyeball movements can be damaged, causing double vision. In addition, the tear duct present in a trough in front of the nose can be damaged, obstructing to tear outflow leading to a watery eye.
• Recurrence of disease: Endoscopic sinus surgery provides significant relief to a substantial number of patients suffering from sinusitis. The underlying cause for sinusitis, such as allergies, will need long-term medication as the sinus surgery by itself cannot cure the underlying cause. Non-adherence to such prescribed medication can lead to recurrence.
• Change in the voice: The voice tone has a nasal resonance quality. When the nose is blocked, which is very common in patients having chronic sinusitis, the nasal tone is absent. You can easily understand what I am trying to convey by simply pinching your nose while speaking, and you will immediately notice the change in the way your voice sounds. On relieving the nose block and removing any polyps/ mass obstructing the nasal cavity, the nasal tone is restored, and you will notice a change in your voice.
• Reduced sense of smell: Although the total or partial loss of smell is reported as a complication, its occurrence is rarely seen. Most of the patients say that their sense of smell has improved after surgery,
• Septum surgery complications: When nasal septum surgery is combined with endoscopic sinus surgery, few complications can be seen. Bleeding and infection in the nasal septum can occur. Septal perforation can occur when there is a through and through an opening in the septum. These patients can experience nose blocks and rarely noisy breathing. Altered sensation in the upper teeth, the lip can last for a few months after septum surgery.
• Bruising around the eye can sometimes be seen after functional endoscopic sinus surgery. This is more common in patients who undergo rhinoplasty (correction of the outer appearance of the nose) along with endoscopic sinus surgery.

What are the side effects of Endoscopic Sinus Surgery?

As I have mentioned above, most of the patients undergoing functional endoscopic sinus surgery have significant benefits. There are very minimal side effects when an experienced sinus surgeons team, such as the one at Sinus Doctor’s, does a nose and sinus surgery. Advanced equipment also plays a significant role in reducing the occurrence of side effects.

The common side effects seen after endoscopic sinus surgery in the order of rare to very rare are

1. Bleeding
2. Septum surgery complications
3. Change in the voice
4. Bruising around eye
5. Reduced sense of smell
6. CSF Leak
7. Vision problems

What is the success rate of Endoscopic Sinus Surgery?

The success rate of endoscopic sinus surgery is reported to be between 85-90% in national and international ENT journals. At our Sinus Doctor centre, we have reported a more than 95% success rate.

This high success rate at our centre is attributable to the following factors

1. Skill of the surgeons team – Having done 1200 basic to advanced sinus surgeries every year for the last ten years, the Sinus Doctor surgeons team has developed systems, checklists, processes to ensure a smooth, safe and successful sinus surgery. We developed many revolutionary techniques in sinus surgery, like “No Pack” sinus surgery, where no nasal packs are placed in the patient’s nose after surgery. This is a significant discomfort for most of the patients. Few patients express more anxiousness about having their nose packed than about getting the surgery done.

2 . Advanced techniques and types of equipment – usage of micro shaver systems, coblation, robotic Co2 laser (one of 3 centres in Telangana having it) maximal mucosal preservation is done during endoscopic sinus surgery, allowing faster recovery and preserving natural sinus drainage mechanisms preventing recurrence. In addition, regular use of sinus navigation by our surgeon Dr. Chaitanya Rao who is specially trained in it, allows for complete removal of disease while avoiding any harm to critical structures, is a crucial factor in the > 95% success rate at Sinus Doctor.

3. Selection of cases – All cases are medically managed adequately, and surgery is advised only to patients who are not responding well.

4. Patient counselling – We educate patients about their disease status, what realistic expectations of having from surgery, the underlying cause causing sinusitis in the patient and when needed about how to manage the underlying cause on a long term basis.

To know more about Endoscopic sinus surgery in india, You can consult the best ENT Specialist in India, He is one of the few Indian ENT specialists to have undergone training in Advanced Sinus Surgery at IRCAD Taiwan. His special areas of interest include Nose & sinus surgeries, Otology, Snoring and Sleep Apnea surgeries. He is the Managing Director of Dr Rao’s ENT.