Sinusitis for Physicians

This section is developed specifically for physicians. It does not necessarily mean that non-physicians can't read it, as there are few ways that we can limit that. It does mean however, that we will be technical in our language and discussions will be based on medical terminology which may be difficult to understand or misconstrued by a lay person. In addition, any recommendations made here should not be used without being under the supervision of a physician well experienced in treatment of sinusitis.

This section is based in part on practice parameters which were developed by the Sinusitis Committee of the American Academy of Allergy, Asthma and Immunology, of which I am a part. I mention this only for the purpose of properly crediting the source of much of this material. It is NOT in any way meant to imply any endorsement of any kind by the Academy. The practice parameters have been published and are now available. There is a link on the bookmark page at the end of this site. It is also based on a recently completed a paper on endoscopic evaluation of patients with sinusitis (both before and after surgery. It is available at http://www.aaaai.org/media/resources/academy_statements/practice_papers/endoscopy.pdf.

Sinusitis can be defined as an inflammation of the mucosal surface of the paranasal sinuses. There are numerous subclassifications, but the most useful definitions include a subdivision between acute and chronic sinusitis, the differential being a three month time period. This is important primarily because the treatment of chronic sinusitis typically may be more complicated and is less likely to be successful, thereby necessitating other management including treatment of allergies, evaluation of immunological function, or surgery. In addition, there have also been other classifications of sinusitis based upon which sinus is involved as well as whether polyps occur, but this classification is not yet well accepted.

Symptoms of acute sinusitis are often confused with an upper respiratory infection and are often manifested as a continuation of upper respiratory symptoms. They can also include purulent or non-purulent nasal drainage (either rhinorrhea or post nasal drip), nasal blockage, the sensation of swelling in the nose or sinuses, ear symptoms, dizziness, difficulty concentrating, pain in the teeth, halitosis,pain on leaning over, fever, headache, cough, malaise, pharyngitis, etc. Gastrointestinal and even psychiatric symptoms are not unusual due to swallowing mucus. Differentiating between sinusitis and a URI on a CT scan is difficult or impossible. Symptoms of a chronic sinusitis may vary, but typically will involve one or more of the symptoms of an acute sinusitis. Symptoms are typically less severe in chronic sinusitis. It is typical that chronic sinusitis symptoms may wax and wane and have a tendency to be relatively minimal.

Anatomy

The most important element in development of sinusitis is the ostiomeatal complex consisting of the outflow tracts of all of the sinuses into the nose, but most importantly the maxillary and ethmoid sinuses. Depending on the anatomy of the outflow tract (diameter, length, as well as configuration), obstruction may occur causing a sinusitis, both in the maxillary as well as ethmoid, frontal and sphenoid sinusitis.

The most common site of sinusitis is the ethmoid sinuses, which typically occurs as a result of obstruction of mucociliary drainage, which then causes a secondary maxillary sinusitis.

Sinusitis involving the sphenoid sinus typically is unusual for children under age 5 and frontal sinusitis typically does not occur until age 10, as a result of later development of those sinuses in children.

Anyone who treats patients with difficult sinusitis should review the anatomy carefully in order to more fully understand the disease process, especially if endoscopy is going to be utilized.

Physiology

The cilia move mucus toward the naturally occurring ostium. If the cilia are interfered with, stagnation of mucus typically will occur. Such can occur with exposure to noxious agents such as tobacco smoke. In situations where the ostia are obstructed, such as with inflammation, viruses, allergic rhinitis, foreign bodies, and polyps, mucociliary clearance will be impaired. The reduction in patency of the ostium typically will cause a reduction in oxygen content within the sinuses, increasing the likelihood of bacterial overgrowth. In situations where nasal breathing is obstructed, a dramatic reduction in oxygen content within the sinuses will also occur.

A change in air pressure inside the sinuses will cause localized pain. This can occur both from obstruction of the ostia and increased mucus production, as well as a change in air pressure such as with flying or diving. For this reason acute treatment is more important prior to such activities.

Bacteriology

The most common isolates in sinusitis are due to S. Pneumoniae, H. Influenzae, M. Catarrhalis, S. Pyogenes, and S. Aureus as well as anaerobes and gram negative bacteria. The first three organisms are most commonly isolated, whereas the others more commonly occur in chronic sinusitis.

Fungal sinusitis may cause acute infection especially in immunocompromised patients. Although previously thought to be unusual, fungal sinusitis is now thought by many to be the primary cause of chronic sinusitis (vide infra). Commonly a black material may be found in the sinus as a result of a fungal sinusitis. Some of the more common fungi involved include Aspergillus, but many different organisms may be involved. Bony destruction may occur as a result of fungal sinusitis, which is discussed later.

Clinical History

Patients with chronic sinusitis may present with a variety of histories which may make diagnosis difficult. Unexplained worsening of asthma is not unusual. Worsening of other allergic symptoms including allergic rhinitis, eczema, etc, may also be a clue. Nasal polyps and rhinitis medicamentosa may also worsen symptoms. Although uncommon, in the differential diagnosis of sinusitis, one must consider cystic fibrosis, (especially in children with polyps), HIV infection, Wegener's granulomatosis, tumors, etc.

Physical Examination

Evaluation of the respiratory tract may in some cases be completely normal, however more commonly, patients will have one or more of the following symptoms: nasal turbinate swelling and erythema and injection, mucus, tenderness over the sinuses, allergic shiners (dark circles under the eyes), pharyngeal erythema or erythema of the lymphoid follicles in the pharynx, otitis, lymphoid hypertrophy, etc. Signs of asthma are not at all unusual.

When the nose is examined, the anterior rhinoscopy done with a nasal speculum is often inadequate in evaluating sinusitis. Although a competent rhinoscopist may be able to see into the middle meatus and the middle turbinate, in patients with active nasal disease, the swelling may be severe enough that it is impossible to adequately visualize these structures to determine an etiology. In situations where one is able to see adequately, purulent secretions and erythema may be seen, as opposed to the pale, swollen, boggy turbinates with thin clear secretions in allergic rhinitis. With the newer, narrower endoscopes, it is often possible to visualize the mucosal surface inside the maxillary or sphenoid sinus in over 50 % of patients.

Because otitis commonly occurs in patients with sinusitis, otic examination is extremely important. I use the analogy of water cascading over a waterfall splashing into the mouth of a cave on the side of a waterfall to explain how inflammatory material dripping down the back of the nose causes inflammation in the ears from the secretions of sinusitis.

Nasal polyps also can obviously contribute to nasal congestion and predispose to sinusitis. It is common that these cannot be seen on anterior nasal examination and must be evaluated via nasal endoscopy and CT scan in order to provide adequate evaluation and treatment. Nasal polyps occurring in children should raise the suspicion of cystic fibrosis which should be evaluated. In adults, polyps should raise the suspicion of the triad of aspirin sensitivity, asthma and nasal polyps. Treatment with steroids and other agents discussed below is often necessary.

In patients who have chronic sinusitis, other evaluations are often necessary including immunodeficiency, allergies, dysmotile cilia, and foreign bodies.

Endoscopic rhinoscopy is used to evaluate the upper nasal airway down to the level of vocal chords. An experienced endoscopist can use information gleaned on nasal examination to determine the proper course of medical or surgical therapy. In addition, evaluation for polyps, septal deviation, adenoidal enlargement, bony spurs, turbinate hypertrophy, obstructed meatus, septal perforation, etc, can be helpful in evaluating the proper course of treatment.

After surgery, the rhinoscopist can evaluate for bleeding, healing, scar tissue, recurrent infections, polyps, etc, to determine progression of healing and development of disease. Caution must be used however as numerous patients may have completely normal post operative findings but still complain of symptoms which may need to be evaluated with CT scans when indicated. Patients may return after surgery with persistent symptoms, but sometimes it takes an extensive evaluation to find the cause.

Radiography and other imaging techniques

Transillumination of the sinuses and ultrasound have a minimal degree of usefulness except under rare circumstances. Plain films are now rarely done, although occasionally in patients with acute sinusitis they may be helpful. Because of the fact that in many institutions CT scans may be obtained for approximately 50% more in cost than plain films, for the most part limited CT scans with coronal views are commonly done. Typically views may be primarily focused on the area of the ostiomeatal complex. Caution must be observed as viral URI's have been demonstrated to cause thickening of the mucosal lining on CT scan analogous to findings with sinusitis. MRI scans are generally less useful except in fungal disease. Several representative CT scans are located in another section of this website.

Laboratory Tests

Nasal cytology can be extremely helpful and is an extremely inexpensive diagnostic tool. Cytology with a Rhinoprobe,(800-654-0146 or 801-489-8911), a small toothpick-like device for sampling of mucosal tissue, can differentiate between allergic disease or fungal sinusitis with eosinophils versus neutrophils in the case of bacterial sinusitis. Evaluation for cystic fibrosis in children may need to be made under appropriate circumstances. Ciliary dysfunction may need to be considered in patients with recurrent sinusitis. The saccharine test, in which a pellet of saccharine is placed in the nose with subsequent development of the typical taste in the mouth, may be helpful in assessing mucociliary dysfunction (normal transit time is 8-12 min.).

Immunodeficiency evaluation in patients with recurrent sinusitis, otitis or pneumonia is indicated including total immunoglobulin levels and possibly immunoglobulin subtypes. Antibody responses to Hemophilus, Tetanus/diphtheria and Pneumovax, and possibly isohemaglutinins may need to be evaluated by the allergist/immunologist. HIV assessment may also need to be made in appropriate patients.

Associated disease

Allergic rhinitis commonly occurs in association with sinusitis, and sinusitis may also cause worsening of associated allergic rhinitis. Patients with recurrent sinusitis should be evaluated for allergies to appropriate food and inhalant allergens and may necessitate treatment with environmental controls, antihistamines, and allergy immunotherapy in addition to medications commonly used in treatment of sinusitis.

Patients with sinusitis commonly may have worsening of symptoms at night which may cause exacerbation of nocturnal asthma. Sinusitis may cause worsening of asthma as a result of the sinobronchial reflex, mouth breathing (inadequate humidification and temperature control), post nasal drip containing inflammatory chemicals from the sinuses, exacerbation of polyps, and infectious material dripping into the lungs.

Reflux symptoms can exacerbate sinusitis and must be evaluated.

Intranasal Steroids and Antiinflammatories

Intranasal steroids form an important part of the treatment of most patients with acute and chronic sinusitis, although studies evaluating the efficacy have not been conclusive. Patients commonly note improvement in symptoms within several days and initially may need o.d. or b.i.d. dosing, but eventually treatment can be tapered down to several times per week. Most patients prefer non-aerosol forms of treatment. Systemic steroids are typically used in patients with more severe disease, but most of the time are not necessary. There are a large number of steroids available now, and the physician must develop familiarity with them to determine which ones work best. Often different steroids need to be used sequentially to determine which one is optimal. NSAIDS can sometimes be used in patients who can tolerate them and are not sensitive to them. Oral steroids may also need to be used.

Decongestants

Oral decongestants typically reduce mucosal edema and increase the patency of the ostia. Topical decongestants must be used with caution, but typically may be used for 3-7 days. Longer use may cause rebound and Rhinitis Medicamentosa. Decongestants commonly may cause significant side effects including insomnia, hyperactivity, dizziness, etc, and dosages may need to be reduced in appropriate circumstances. Recent studies suggest that most hypertensives can use oral decongestants without significant exacerbation of hypertension.

Mucolytics

Guaifenesin in high doses is often helpful in increasing clearance of secretions as well as thinning secretions. Efficacy has not clearly been proven, but most practitioners find that it is helpful. The mechanism may simply be to increase the amount of fluids ingested by patients as guaifenesin typically causes extreme thirst. Nausea and other GI disturbances are not unusual and may be alleviated with a reduced initial dosage progressively increasing to maximal dose. Potassium iodide may also be useful in selected patients. Iodinated glycerol was also helpful prior to being taken off the market.

Buffered saline lavage may help in clearing secretions. Hot steam is often helpful, especially at night, when nasal secretions are typically not cleared. The Rhinotherm nasal steam machine is helpful in some patients, although studies have been inconclusive. Irrigation with a water pik and Grossan nasal irrigator (or hydropulse) may be helpful in some patients.

Antihistamines

Antihistamines must be used cautiously as a result of drying of secretions which may then remain inside the sinuses. In patients with significant allergic symptoms, antihistamines do clearly have a place in treatment. Topical antihistamines such as Astelin may be helpful in some cases.

Adjunctive Treatment

A variety of nonmedicinal agents have been used in order to treat sinusitis. Among the more popular ones are eucalyptus oil which when smelled may increase mucociliary clearance. Some patients have also claimed that garlic is also helpful in that regard. I have even had patients who put garlic cloves in their nose! Claims have been made that a variety of other agents are effective, but have not been proven including vitamin C, multivitamins, Echinacea, quercetin, etc. Numerous other agents have been used in Europe. We cannot endorse any of these agents as little work has been done with them.

Antibiotics

We have deliberately included antibiotics at the end of this section to emphasize that antibiotics alone should not be relied upon to clear sinusitis. Antibiotic penetration into the sinuses is typically relatively poor, comparable to osteomyelitis. As a result, treatment generally must continue for at least two weeks in acute sinusitis and at least three weeks in chronic sinusitis. Six to eight weeks of treatment is not unusual. Generally we treat patients for at least one week after symptoms have resolved. Other medication may need to be continued for an extended period of time after treatment.

Antibiotic therapy must be based upon knowledge of likely microorganisms. Results of nasal cultures are not reliable as they do not correspond with sinus cultures, however cultures directed endoscopically into the drainage areas of the sinuses or directly into the sinus cavity may be helpful. A sinus secretion collector (Medtronic/Xomed) has also been developed which is helpful in securing cultures. Sinus aspiration is generally not done because the amount of pain and because of the risk of introducing bacteria into the sinuses. Medications must be based on the likelihood of a resistant organisms, previous antibiotics used, duration of treatment, allergies, etc. Amoxicillin, sulfamethoxazole/trimethoprim, or erythromycin ethylsuccinate/sulfisoxazole acetyl (Pediazole) in children are reasonable to use and inexpensive for initial treatment, however, resistant organisms commonly occur. Erythromycin, penicillin, and tetracycline are generally not effective because of inadequate coverage.

In patients with chronic sinusitis, antibiotic coverage must include resistant S. Pneumonia, H. Influenza, M. Catarrhalis, and S. Aureus. Patients must also be evaluated for other organisms depending on previous antibiotic treatments, work history, etc. Appropriate antibiotics may also initially include amoxicillin/clavulanic acid (Augmentin), cefaclor (Ceclor), cefuroxime axetil (Ceftin), loricarbef (LoraBid), cefprozil (Cefzil), cefdinir (Omnicef), clarithromycin (Biaxin),and azithromycin (Zithromax). In patients with chronic sinusitis, consideration must also be given to anaerobic and gram-negative coverage and appropriate treatment may need to be made under those circumstances. Consideration may also need to be made to resistant organisms such as Pseudomonas which may need to be treated with drugs such as Ciprofloxacin (Cipro). In some patients treatment may be necessary with drugs such as levofloxacin (Levaquin), or newer quinolones such as moxifloxacin (Avelox), and gatifloxacin (Tequin). Patients who are suspected of having anaerobes may need to be treated with clindamycin (Cleocin) or metronidazole (Flagyl). Telithromycin (Ketek), Cefpodoxime (Vantin), cefixime (Suprax),and ceftibuten (Cedax) may also be used under some circumstances. We often will leave patients on antibiotics for 4 - 5 days, and if they have not responded, alter the regimen. Often patients will need multiple antibiotics, either sequentially or simultaneously.Prophylactic antibiotics remain controversial as resistant organisms and fungal sinusitis may occur despite treatment.

Intravenous antibiotics may be used in situations where oral antibiotics have failed, or as preparation for surgery. In some cases of osteitis, it may be felt by the specialists that healing may not be adequate after surgery. Antibiotics may be continued after surgery as well. Specific antibiotics should be chosen based on sensitivities, however a combination such as ceftriaxone and clindamycin has often been used. (Sinucare has been instrumental in starting this.)

IVIG

Intravenous gammaglobulin is appropriate in patients who have recurrent sinusitis with appropriate immune deficiencies. Routine immunoglobulin treatment in patients without immunodeficiencies has not been found to be helpful, is expensive, and very difficult to terminate. In addition, severe shortages have occurred with some desperate patients being unable to obtain IVIG.

Fungal Sinusitis

An article published in the Mayo Clinic Proceedings in September, 1999 by the Mayo Clinic suggests that fungal sinusitis may be much more common than previously thought. The disease is now know as EFRS (eosinophilic fungal rhinosinusitis) or EMRS (eosinophilic mucinous rhinosinusitis).

Fungal growth was found in washings from the sinuses in 96% of patients with chronic sinusitis. Normal controls had almost as much growth, the difference being that those patients with chronic sinusitis had eosinophiles which had become activated. As a result of the activation, the eosinophiles released MBP (Major Basic Protein) into the mucus which attacks and kills the fungus but is very irritating to the lining of the sinuses. It is believed that MBP injures the epithelium and allows the bacteria to proliferate. An assay has been developed for major basic protein (MBP) which may be helpful for evaluating sinusitis due to fungal disease.

The injury to the epithelium by the fungus and mucus led to the belief that treatment of chronic sinusitis should be directed at the fungus rather than the bacteria. Obviously the optimal treatment would address the reason the eosinophiles attack the fungus, however, at the present time, we do not know the reason.

Unfortunately the discussion above was not included in the original article by the Mayo clinic. As a result, the article was not well received initially. There was also no information about the success of treatment in the original article, and there was very little discussed about mechanisms. As more data has accumulated, there is more evidence that the problem may be as important as the Mayo Clinic suggests and the significance is starting to be accepted.

The findings of the Mayo Clinic were confirmed in papers presented at the Nose 2000 meeting of the The American Rhinologic Society. The well respected group from Graz, Austria were able to show positive fungal cultures in 92 % of their patients. Almost as many of the controls also had fungi. Clusters of eosinophiles were found around fungi in 94 % of patients. This is important because we believe that this shows that the eosinophiles are involved in attacking and killing the fungi.

Current techniques make it difficult for private practitioners to clearly establish EFRS. For example, it is possible to tell by electron microscopy that the degranulation of the eosinophile is in response to fungus. The granules will form a horseshoe shape after degranulation, which is specific to activation by fungi. There are also special stains (e.g. chitinase) which the Mayo Clinic has developed which hopefully will be available in the future. As mentioned above, it is also possible to tests for MBP in the mucus, which is not found in normals.

At the present time, patients are being treated with irrigation with topical antifungals such as itraconazole or Amphotericin B with 75 % having an improvement. Many patients require other agents such as nasal or systemic steroids, however many patients were able to stop treatment with steroids. Some physicians have also used oral antifungals. A study has begun which will hopefully lead to the approval by the FDA of the first treatment for chronic sinusitis. This involves a new formulation of Amphotericin B. For more information on the study, please contact Accentia Pharmeuticals

Some doctors have added antifungals ( or antibiotics ) to the Grossan irrigator. One method is to add 1 tsp of salt ( or Breathease, or salt-baking soda solution ) to 500 cc of water in the Hydropulse and irrigate. When the solution is almost gone, it is possible to add the antifungal to the irrigation fluid and continue irrigating. The antifungal solution should not be added at the beginning because it may become too diluted.

Given topically, Amphotericin B causes minimal problems. These can include burning due to the fact that it must be mixed with sterile water. It cannot be mixed with saline, and must be protected from light and refrigerated. It is therefore very inconvenient to use.

Itraconazole must be specially formulated. At the present time, it can only be formulated correctly by a limited number of pharmacies including AnazaoHealth, and Sinucare . We anticipate that patients will need to be treated indefinitely, or at least until we better understand why these problems are occuring.

Because irrigation must get into the sinuses in order to be effective, it is sometimes necessary for patients to have endoscopic sinus surgery before irrigation can be effective. At the same time, it may be possible to use the Grossan irrigator to irrigate effectively without surgery.

It is speculated that since as many as 70% of patients with EFRS have a positive allergy skin test for fungi or mold, it may be possible to treat them by standard allergy management including environmental management and allergy immunotherapy. Since we cannot allergy test for all of the fungi, it can be a difficult proposition, however.

We have found many patients require careful evaluation for fungi in the home environment. In some cases, it may be necessary for a environmental engineer to evaluate for mold in the home or workplace and subsequently have remediation performed. (It can be very expensive to do so, however. For more information, please go to the page on fungal sinusitis.)

There are several other types of fungal sinusitis which are important to be aware of. The other forms of fungal sinusitis are broken down into several categories: Allergic, Fungus balls (Mycetoma), and Invasive.

Patients who have repeated bouts of sinusitis, as well as those who are immunocompromised should be considered to possibly have a fungal sinusitis. CT scan will sometimes show calcification, but MRI is more sensitive in diagnosis. Cultures are best obtained from the sinuses.

Allergic fungal sinusitis (AFS) is commonly caused by Aspergillus, as well as Fusarium, Curvularia, and others. Patients often have associated asthma. The criteria include CT or MRI confirmation, a dark green or black material the consistency of peanut butter called "allergic mucin" which typically contain a few hyphae, no invasion, and no predisposing systemic disease. Charcot-Leyden crystals, which are breakdown products of eosinophiles are often found. Usually patients are found to be allergic to the fungus, although this is controversial. This disease is analogous to Allergic Bronchopulmonary Aspergillosis.

Surgery, irrigation, steroids and immunotherapy are helpful, but it can be extremely difficult to treat. It occurs much more commonly in the humid areas in the Southern United States.

Fungus balls often involve the maxillary sinus and may present similarly to other causes of sinusitis including a foul smelling breath. In addition to radiological abnormalities, thick pus or a clay-like substance is found in the sinuses. There is no allergic mucin, but dense hyphae are found. There is no invasion. There is an inflammatory response in the mucosa. Removal of the fungus ball is the typical treatment.

Invasive sinusitis can progress rapidly, and typically necessitates surgery, often on a emergent basis often requiring Amphotericin as well. There have been some forms of invasive sinusitis which can cause proptosis. There is a form of chronic invasive fungal sinusitis which is associated with visual abnormalities due to bony erosion from the ethmoids.

Fungal sinusitis should obviously be treated by someone with extensive experience in treatment of that disease.

Surgery

We will not attempt to discuss extensively the role of surgery in management of sinusitis, but rather focus on the basics.

If patients have not responded adequately with optimal medical treatment including medications, allergy evaluation, and immunological evaluation, a surgical consultation is typically indicated. By this time, as medical specialists in sinusitis, we would have performed a CT scan as well as nasal and sinus endoscopy with cultures. Under most circumstances we do not refer patients to the otolaryngologist unless we are fairly certain that all medical treatment has been exhausted and the patient will need to have surgery. As a result, over 95% of the patients we refer end up needing to have surgery. Prior to being referred to the surgeon, the patient should be evaluated by an allergist for allergic and immunological evaluation.

After rhinoscopic examination by the surgeon, the patient will typically have functional endoscopic sinus surgery (FESS), as open procedures including the classical Caldwell-Luc operation are generally outmoded. Maxillary osteotomy should occur in the same place as the naturally occurring ostia in the middle meatus, otherwise mucociliary clearance will not allow mucus to be cleared normally. The Caldwell-Luc procedure involved using a trochar to penetrate though the mouth under the upper lip into the canine fossa with creation of an antrostomy in the inferior meatus. This did not provide adequate anatomical drainage due to the natural movement of mucus to the maxillary ostium. (See the CT page in another section of this site for further anatomical reference). Morbidity with the Caldwell-Luc was high and success rates were not as good as with FESS surgery.

Surgery is typically done under either local or general anesthesia depending on the extent of the surgery which needs to be done, the patient involved, and the preference of the surgeon. At the time of surgery, the surgeon will initially correct a septal deviation if necessary. Note that complete correction of the deviated septum may not be feasible if hypertrophy of the turbinates on the contralateral side has occurred. Obviously if that were to happen, the contralateral side could become obstructed as well. Depending upon circumstances, it may be occasionally necessary to slightly trim the turbinates, especially the middle turbinate to access the meatus and sinuses adequately. Most surgeons prefer to limit the amount of turbinate removal as there is some evidence that olfactory sensation may be related to tissue in the middle turbinate. Additionally, removal of large amounts of tissue may create scarring as well as an increase in nasal congestion similar to the phantom limb syndrome, and is called the empty nose syndrome.

An osteotomy is typically made at the site of the naturally occurring maxillary sinus ostium with removal of the uncinate process. If adequate removal of tissue is not made, there may not be an adequate size ostium created for drainage, and scar tissue may cause obstruction. Depending upon the patient, the anterior and/or posterior ethmoid sinuses may also need to be removed, either partially or in toto. In some cases, the sphenoid sinus may also need to be surgically entered. Ethmoid (particularly posterior) and sphenoid surgery is more difficult than the maxillary antrostomies. The ethmoid sinuses are different than the maxillary and sphenoid sinuses in that they are a honeycomb, and as a result must be resected so that adequate drainage occurs without compromising vital structures. Under most circumstances the frontal sinus does not need to be entered, although the frontal recess may need to be resected.

In general, most surgeons prefer to do minimal surgery, i.e. not stripping the mucosa as patients generally do better in the long run. Adequate drainage is often enough such that more radical surgery does not need to be performed.

The success rate and operative complications are dramatically related to the skill of the surgeon. There is a very long, steep learning curve. Typically, in the first 100-300 cases, surgeons will have a much higher complication rate which may include meningitis due to perforation, orbital cellulitis, blindness due to severing the optic nerve, etc. There are a large number of otolaryngologists who perform endoscopic surgery, but many of them may not perform the surgery well.

Post operative care is extremely important, as patients must be diligently followed in order to prevent adhesions and other complications.

It is important to realize that surgery does not prevent future episodes of sinusitis. The ostium is enlarged, therefore providing adequate drainage. It is analogous to draining an abscess. A sinusitis is similar to an abscess and the surgery allows adequate drainage. It does not ensure that there will be no more problems with the abscess. In addition, future sinusitis can occur, but can be more adequately treated because drainage is better.

After surgery, we often find that patients do not need oral antibiotics but with reduction of inflammation, irrigation and mucolytics, they will often respond well to treatment. In some patients, irrigation with antibiotics such as Gentamicin may be helpful.

Patients typically are out of work for approximately 1-2 weeks after surgery and typically take approximately 6 weeks to heal. It may take 6-12 months for the healing process to be completed, however.

Despite good surgical technique, a small percentage of patients who have had surgery do not improve optimally. The reasons for this include adhesions, development of sinusitis in sinuses not previously operated upon, polyps, exposure to irritants or toxins, especially tobacco smoke, inadequate initial surgery, poor compliance with medications, inadequate treatment of allergies, immunodeficiency, other medical problems, etc.

In our experience, re-operation is unusual with good medical and surgical management, but it does occur. Sometimes this can be done in office, especially if the patient needs minor lysis of adhesions. If extensive reoperation is necessary, it is important to choose a surgeon with appropriate experience. With the newer technique of image guided surgery ( see the section later on this website), it is often possible to reduce the risk of reoperations.

If patients have allergies, it is important to manage the allergic problems, including immunotherapy as needed. We have had numerous patients who had extended symptoms after surgery, but with good allergic management, their symptoms resolved completely. This incidentally has even occurred in several patients who I was convinced needed to have surgery, but for a variety of reasons the patients elected not to have surgery .

Additional information for physicians which was written by Dr. Tichenor can be found in the links in the Bookmarks section under Medscape Respiratory Care.

If you would like information on the newest technique in surgery please go to the page on

The contents of sinuses.com © 1998-2007 by Wellington S. Tichenor,M.D. Last update April 22, 2007. Reproduction for educational, not-for-profit purposes is permitted if this source is credited and the author of this website is notified of any reproduction for other than personal use. If used on the internet, a link would be appreciated.