In one study that looked at surgical records from the state of
Maryland, the number of sinus surgeries performed in that state increased
almost ten-fold over the past ten years. Does this mean that the number
of people with sinus disease increased by 1000% during this time period?
Probably not. While it is certainly true that the introduction of endoscopic
sinus surgery has made operating on the sinuses safer and appropriate
for a greater number of patients, it is also probably true that some physicians
have been over-zealous in their use of sinus surgery is a “cure-all”
for a variety of symptoms.
The Evolution of Sinus
Sinus surgery has been around for quite some time. Originally, access
to the sinuses was obtained by incisions on the skin or gums. Later, headlights
and surgical instruments were designed that allowed surgeons to operate
through the nose. However, visualization of the sinuses while operating
was not optimal, and much of the procedure was done more by feel than
by direct visualization. The introduction of endoscopes in the 1970’s
and 80’s changed all that. Endoscopes are small “telescopes”
that are inserted in the nose and allow the surgeon to obtain a close-up
view of the operative field. Often a miniature television camera is attached
to the endoscope so that the entire operation can be viewed on a TV screen
as the surgeon operates.
The originators of endoscopic surgery emphasized that the basis of the
technique was the belief that small areas of blockage where the sinuses
empty into the nose could be responsible for fairly widespread sinus disease,
as the secretions, etc. backed up into the sinuses. Optimal treatment
consisted of careful, limited removal of the blockage while disturbing
as little of the sinus as possible. The use of endoscopes and endoscopic
instuments made such delicate work feasible. The belief was that the remainder
of the sinuses would gradually heal themselves now that they could drain
in a normal way. The originators of this type of surgery coined the term
“Functional Endoscopic Sinus Surgery” (FESS) to emphasize
that the goal of the surgery was to restore normal function to the sinuses
by disturbing them as little as possible.
In the great American tradition of “If a little is good, a lot is
better.” I have seen the original premise of FESS ignored by some
surgeons who routinely open up every single sinus in a patient’s
nose regardless of the amount of disease. Because of extensive postoperative
scarring, the likelihood of these sinuses ever regaining normal function
is low. I believe that a careful, conservative approach, in which the
original intent of the surgery is respected, is best in the long run.
When to Have Sinus Surgery
There is no easy answer to this. Obviously, one needs to balance the risk
of complications against the likelihood that surgery will help your symptoms.
Fortunately, the complication rate of FESS is quite low. However, serious
complications such as brain fluid leak, meningitis, and damage to the
eye can and do occur. As to whether surgery will help, this is something
that needs to be answered in an honest, unbiased manner by your doctor.
For example, in a patient that has nasal polyps and complains of nasal
obstruction, I can tell them that I am almost 100% sure that surgery will
help them. On the other hand, in a patient with chronic headaches and
minimal sinus disease, I would be much less confident that surgery will
be of benefit.
One of the newer innovations in sinus surgery involves a technology called Balloon Sinuplasty. You may have heard about this in the local news (USA Today, WRAL). It is a minimally invasive option that is clinically proven to safely and effectively open the sinuses. Similar to traditional endoscopic sinus surgery, cameras are used to visualize the sinus openings. However, rather than using cutting or shaving instruments, a small flexible balloon catheter is placed into the diseased sinus and gently inflated to widen the opening into the sinus while maintaining the natural lining of the sinus. This is analogous to angioplasties done in patients with heart blockages. The surgeons at Carolina ENT are certified to use the Balloon Sinuplasty system. We are happy to discuss with you whether or not the Balloon Sinuplasty system is appropriate for you. For more information, please go to www.balloonsinuplasty.com