Published in Panorama
Surgery in treating sinusitis
A common cold or a headache accompanied by cold is very often interpreted by the lay public as a “sinus” or “sinusitis”. The word “sinusitis” is very liberally used to describe what may actually be a simple cold or headache, says Dr.Bakul Kotak, ENT Specialist, Welcare Hospital, Dubai.
Sinuses are hollow air spaces located within the skull or bones of the head surrounding the nose. Frontal & Maxillary are the paired sinuses & Ethmoid & Sphenoid being a single midline sinus. When symptoms appear in one or more of these cavities, one is said to suffer from a sinus attack or sinusitis. These cavities include the Frontal sinuses above the eyebrow area, Maxillary sinuses inside each cheekbone, Ethmoid sinuses just behind the bridge of the nose and between the eyes and the Sphenoid sinuses behind the ethmoids in the upper region of the nose and behind the eyes. A continuous lining of mucous membrane links these sinuses to the nasal passages and each sinus has an opening into the nose for free flow of air from nose to sinuses and for mucous secreted by lining of sinuses to drain in to the nasal cavity. Because of this communicating passage between the nose and the sinuses, anything that causes an inflammation in the nose, can affect the sinuses as well, explains Dr.Kotak. And this can happen due to infection or an allergic reaction.
Most cases of acute sinusitis start with a common cold which is caused by a virus. While these viral colds do not in themselves bring on sinusitis, they do inflame the sinuses. Air and mucus may get trapped behind the narrowed openings of the sinuses, preventing proper drainage, thus making conditions ideal for bacteria to multiply. Bacteria such as streptococcus pneumoniae and haemophilis influenzae which are present in the upper respiratory tracts of most healthy individuals, may actually now invade the sinuses, when a person's immune mechanism is in a weakened state. This may cause an acute sinus infection, explains Dr.Kotak.
Who are the people prone to sinusitis? Dr.Kotak explains, "Firstly, people who have had trauma on the face as happens in sports accident like football players. These are the people who could develop bends of the partition of the nasal septum, which predisposes them more to develop infections as compared to others. Secondly, some individuals are born with a condition called muco-vicidosis where the mucus secreted by their mucous membrane is more viscous, due to which they are more prone to sinusitis. Thirdly, certain individuals are predisposed to allergies, again genetically. In these individuals, the lining of the nose swells up due to the repeated exposure to the allergen. This swelling obstructs the free channel of air flow and it also increases the chances of developing infection. Sometimes there may be a nasty fungal infection, especially in immuno-compromised individuals and diabetics, leading to sinusitis, explains Dr.Kotak.
What are the symptoms of sinusitis? Typically, the symptoms of sinusitis, resemble that of a cold, with runny nose, stuffed nose and headache. Headache when you wake up in the morning is typical of a sinus problem. Only headaches, though are commoner in chronic than in acute sinusitis, reveals Dr.Kotak. However, the location of sinus pain depends on the sinus that is affected, though most people with sinusitis may complain of pain or tenderness in several locations and their symptoms may not clearly indicate which sinuses are inflamed. For instance, though rarely affected, if the sphenoid sinuses are involved, the patient may experience neck and ear pain and deep aching pain on top of the head. Cheeks may become tender, there may be jaw and tooth ache if the maxillary sinuses are infected. Inflammation of the ethmoid sinus, which is near the tear ducts in the corner of the eye, may bring on swelling of the eyelids and tissues around the eyes, causing pain between the eyes.
Dr.Kotak further explains, "Normally all sinuses must be filled with air. In acute sinus inflammation, the oxygen part of the air is absorbed by the lining of the sinus, creating relative vacuum and causing a pull-effect on to the lining of the sinus because it is a sealed cavity now. This results in headache while bending down. This is very typical of vacuum pains."
How is sinusitis diagnosed? A clinical history of the patient is followed by X Ray/ CT Scan or MRI where needed, to ensure that the problem is one of sinusitis, explains Dr. Kotak. He emphasizes, "It is absolutely important to know that the patient is actually suffering from sinusitis in order to treat appropriately. A sinusitis needs longer duration of treatment as compared to a simple cold. While X Ray is a rule-out tool, I never perform a sinus surgery without a CT Scan as the confirmatory diagnostic tool. CT Scan also helps as a navigator tool during the surgery.
How is sinusitis treated? Medication with antibiotics, nasal steroid sprays, decongestants and antihistamines are generally the first line of treatment for sinusitis. However, when patients have recurrent infection and do not respond to medication, surgery to enlarge the openings to drain the sinuses may become necessary, says Dr.Kotak.
Dr.Kotak further clarifies emphatically, "Since sinus infections are broadly of two types, allergic and infective, it is important for the specialist to distinguish between these two because sinusitis brought on by allergic component, cannot be cured with surgery. Having said this, quite often, there is a combination of allergic as well as anatomical problem causing the sinusitis. In these cases, we first treat the allergy component medically, to manage or control them. But sometimes, the bends in the nasal septum are so bad that even the spray, which is the mainstream of treatment for allergy, cannot go deep in. Then we intervene surgically to open up the airways to enable the patient to breathe freely and for the proper administration of the drug through the spray mode.
Apart from the anatomical problem, what are the other indications for sinus surgery?
Dr.Kotak explains, "Chronic sinus is an indication for surgery. By internationally accepted standards, if the problem has been there for six weeks and more, it is a chronic state. There are a small percentage of individuals who have a chronic purulent pus discharge and have thickened and inflamed lining of the sinuses. This needs to be scraped or removed; surgery is once again indicated in this situation. Similarly, diabetics and immuno-compromised individuals who have sinus infection from fungi or a mixture of bacterial and fungal infection, need to be drained much more vigorously and thoroughly for which surgery is required."
Should surgery be required, can it be performed on all ages of people?
Dr.Kotak explains, "Fortunately, allergic sinusitis is not common under the age of 15-16 years. But having said that, I recently had a boy of 13 months who had an extended application of sinus surgery. Of course this was not a pure sinus surgery. A part of brain was herniating in to his nose that was tackled by endoscopic surgery. As far as sinus surgery is concerned, like any other nasal surgery, we prefer to defer surgery as far as possible till the patient is about 15-16 years of age so that the skeletal development is fully complete. A limited surgery to open up the airway in severe obstruction may be undertaken. Because, the surgery if done earlier, can sometimes hamper the growth if we touch the bony developmental skeleton for surgery."
What does the surgical procedure involve and what is the duration of the surgery itself?
The goal of sinus surgery is to remove the diseased sinus tissue and create an open pathway for infected material to successfully drain from the sinus cavities. Thanks to technological advancements in the medical field, surgeons are able to map out patients' sinus pathways and perform minimally invasive surgery, involving minimum risk and complications, assures Dr.Kotak. While traditionally sinus surgery was done by open methods, the most common and preferred surgical mode today is Endoscopic sinus surgery (ESS) to drain the infection and restore sinus ventilation. The entire procedure can be done entirely through the nostrils, leaving no scars, little swelling or discomfort to the patients. The endoscope, a very thing fiber-optic tube is inserted into the nose for a direct visual examination of the openings into the sinuses. Once the area of obstruction is identified, the abnormal and obstructive tissues are removed endoscopically, reveals Dr.Kotak.
What are the risks involved in ESS? Dr.Kotak explains, "First and foremost, it should be performed by experienced surgeons with expertise. The complications include bleeding, cerebral spinal fluid leakage, damage to the eye and its associated structures. Besides, surgery may fail to resolve the sinus infections or recurrence of sinus problems. There may be excessive dryness or crusting of the nose. There could be damage to internal carotid artery while operating on sphenoid sinus, which could be catastrophic. But having said this, the optic nerve damage and carotid artery damage are extremely rare occurrences in the hands of experienced surgeons."
Surgical time depends on the extent of the problem and could take anywhere between 45 minutes to two and a half hours, says Dr.Kotak. The procedure is normally done under general anesthesia keeping in mind the threshold of the patient's pain, living standards of the patient, and on how deep seated the problem is. "In the developing countries, I have done the surgery under local anesthesia, for instance, when a polyp is present right in front of the nose. Doing under local anesthesia not only saves money, but the operating field is fairly dry giving clear visibility which in turn improves the outcome of the surgery."
Sinus surgery, unlike other types of surgery where a diseased part or organ is removed, involves the re-opening of existing but blocked sinus pathways. Hence, post-operative care is as important as the surgery itself. One of the most common causes of failure of this procedure is poor post-operative care and follow-up. Healing takes places in about 4-6 weeks following surgery. However, patients have to use the local steroid sprays to tackle their allergic problem if they have one, re-emphasizes Dr.Kotak. "We advice patients to have a first check up one week following surgery, and a second one 10 days following the first check up. These first two checkups carry much more weight than the surgery itself for long term prognosis."