Surgical Management of Chronic Rhinosinusitis – FAQs
Chronic rhinosinusitis (CRS) is a long-term condition where the sinuses become inflamed for 12 weeks or longer, leading to symptoms like nasal congestion, facial pain, reduced sense of smell, and nasal discharge. It can significantly affect your quality of life.
How Is the Diagnosis of CRS Confirmed?
Your surgeon will verify if your symptoms meet established criteria for CRS. This includes having two or more key symptoms (like nasal congestion or nasal discharge) for at least 12 weeks, along with evidence of sinus inflammation from a nasal exam, in-office nasal telescope (nasal endoscopy), or imaging like a CT scan.
What Is Sinus Surgery?
Sinus surgery is usually done using a telescope, camera and specialized instruments that go inside the nose. In most cases, there are no cuts or incisions on the outside of the nose or face. It will not change the shape or appearance of your nose from the outside. Sinus surgery can be helpful for CRS, especially in certain types of CRS, or CRS with complications like a collection of infected pus in the brain or eye that started in the sinuses. Sinus surgery can also be performed for tumors arising in the nose and sinuses, or at the bone that forms the barrier between the sinuses and the brain.
How Do I Know if I Need Sinus Surgery?
Your surgeon will assess your candidacy for surgery by evaluating how severe your symptoms are, the type of CRS you have, how much CRS affects your quality of life, any imaging results you have, what treatments you’ve already tried (both medical and surgical), and knowledge of your general health. Surgery is usually considered when other treatments haven’t worked or aren’t expected to work, and the disease is affecting your day-to-day life.
What Are the Benefits of Verifying My Diagnosis before Surgery?
Ensuring that your diagnosis is correct helps to avoid unnecessary surgery and provides the best chance of success if surgery is performed. This process also helps to identify other conditions that might mimic CRS, so that the right treatments are provided and delays in receiving the right treatment are avoided. For example, some patients might have migraine headaches, rather than CRS, so migraine medicines would be better in this case. Part of verifying the diagnosis of CRS also includes understanding your symptoms and how severe they are. As you might suppose, understanding is important for planning how best to take care of you.
What Happens during the Assessment for Surgery?
Your surgeon will talk to you about your symptoms, how CRS is affecting your daily life, and review any previous treatments. They may use questionnaires or scoring systems to measure how much your symptoms are affecting you (like the so-memorably named SNOT-22 test or variants of it that also measure related conditions like allergy). “SNOT” stands for SinoNasal Outcome Test and focuses on how patients feel from their point of view, an important factor during management of disease. Your surgeon will also check for any signs of inflammation in your sinuses using nasal endoscopy or imaging like a CT scan of your sinuses.
What Are the Risks of Verifying My Diagnosis or Assessing My Candidacy for Surgery?
There may be a need to check, review, or even repeat certain tests, such as nasal endoscopy or imaging, which can carry additional costs or minor risks. However, these steps are taken to ensure the diagnosis is accurate and surgery, if needed, is appropriate.
What Makes Me a Good Surgical Candidate?
Often your doctor has evaluated the inside of your nose with a telescope (endoscopy), trialed any medications which could be expected to help your condition, and obtained imaging that provides information about whether you might be a candidate for surgery. Additional considerations for safe surgery include optimizing your overall health with the help of other specialists.
Can I Play a Role in Deciding If Surgery Is Right for Me?
While your surgeon is responsible for confirming the diagnosis and determining if surgery is appropriate, your input is vital. You will be asked about how CRS impacts your quality of life and daily activities, and your surgeon will take this into account when discussing your treatment options. Sometimes the questionnaires like the one described above provide a common ground to begin these discussions. Your doctor can share the process of decision making as you learn more about CRS and sinus surgery.
Are Antibiotics Helpful for My Chronic Sinus Disease?
Antibiotics are used to treat bacterial infections, so they are not always helpful for CRS, which isn’t always triggered by bacteria. CRS is often due to inflamed sinus passages, although it is possible that bacterial infections (on top of existing inflammation) can occasionally cause more severe flares in symptoms.
Antibiotics are routinely used to treat patients with pneumonia (lung infections resulting in shortness of breath and coughing with thick and discolored mucus) and urinary tract infection (kidney and bladder infections resulting in cloudy urine) because these types of infections are commonly caused by bacteria. Acute sinus infections that start suddenly, resulting in thick, discolored nasal drainage and nasal congestion for more than seven to 10 days may also be treated with antibiotics. Unlike acute sinus infections, chronic rhinosinusitis results in symptoms that last longer than 12 weeks.
These symptoms occur because of tissue swelling within the nose and sinuses, and do not necessarily involve a bacterial infection. For this reason, antibiotics are not recommended for all patients with chronic sinus disease. Antibiotics can be harmful if they are not prescribed for the right reasons. Side effects of antibiotics can include gastrointestinal (GI) upset or more severe GI infections like Clostridioides difficile, genitourinary infections, skin rashes, joint problems, and ear symptoms. Antibiotics can also become less effective in treating infections if they are used too often. If you are a patient with nasal drainage that is thick and discolored, it is usually helpful to see a clinician who can carefully examine your nose and sinuses. The examination will help determine if there is an active bacterial infection and if antibiotics should be prescribed to treat a sinus infection.
Will Surgery Replace My Need for Most Sinonasal Medications?
In many cases, surgery is not a replacement for medications; rather it is part of your treatment and allows topical medications to work more effectively.
Are There Alternative Treatments to Surgery?
Yes, medical treatments include nasal sprays, sinus rinses, oral antibiotics, or steroids may be used to manage CRS. Surgery is generally considered when these options have not provided enough relief, and your surgeon will review all prior treatments before recommending surgery.
What Is the Difference between Sinus Dilation Surgery and Sinus Surgery Creating Wide Sinus Openings?
Sinus dilation uses an instrument such as a probe or a balloon to widen the opening into a sinus. Frequently, the goal is to widen the natural sinus opening. The sinus dilation procedure does not involve the removal of bone or tissue. Surgery to create wide sinus openings involves removing tissue, bone, or both. This is similar to turning a honeycomb into one large space instead. The goal is to enlarge the opening into the sinus cavity to allow the sinuses to drain better. The goal is to enlarge the opening into the sinus cavity to allow the sinuses to drain better. Depending on the characteristics of your sinus disease, a wider opening may be necessary.
How Does Creating Wide Sinus Openings Help My Chronic Sinus Disease?
Creating wide sinus openings can help in several ways, including:
- Large sinus openings allow your surgeon to access disease, mucus, and infected tissue in your sinuses during surgery.
- Large sinus openings make it easier to get saltwater sinus rinses into your sinuses. The sinus rinses help clean the sinuses and remove accumulated mucus from your sinuses.
- Large sinus openings enable the delivery of medications topically in sprays and in the sinus rinses to help control your sinus disease. An example is the delivery of topical steroids, which may be given as a nasal spray or as an additive to the sinus rinses.
- Large sinus openings let your sinus surgeon see into the sinuses during an in-clinic endoscopic exam to monitor your disease. The large openings will also enable your sinus surgeon to clean the sinuses if you develop an infection.
What Should I Expect after Surgery? Should I Expect Pain?
Surgery does result in some degree of discomfort during the healing process. In general, pain after sinus surgery is often mild to moderate. Our goal as surgeons and clinicians is to make you as comfortable as possible while you are recovering from surgery. Your surgeon may recommend over the counter (OTC) pain relief medications such as acetaminophen (Tylenol®), and some may permit ibuprofen (Motrin®, Advil®). Stronger prescription pain medications such as narcotics may be used, but it is rare that they would be necessary for long or even intermediate periods of time. Many patients do not need narcotic pain medications at all. Some patients find that the degree of nasal congestion or stuffiness feels worse during the initial recovery from surgery due to swelling and mucus production by the healing tissues. This congestion may be bothersome and can sometimes cause headaches or throat discomfort. Your surgical team can help you manage these other symptoms as well and will let you know when it is safe to resume nasal irrigations and sprays.
What Type of Postoperative Care and/or Medications Will I Need, and for How Long?
Depending on your type of sinus disease, postoperative care may include nasal saline irrigations with or without added medications, oral antibiotics, or oral steroids, which may need to be continued well after the postoperative recovery period to control sinus disease.
How Many Postoperative Visits Will I Have, and What Is the Timing for These?
Most patients will be seen regularly after surgery. A common regimen of visits is between one to two weeks after surgery, one to two months after surgery, and then at regular intervals for one year or more following sinus surgery.
What Will Be Covered or Done at These Postoperative Visits?
The first few visits may require nasal endoscopy and debridement (removing old clots, crusts, or any packing placed in the nose). Debridements can also sometimes be uncomfortable. Discuss with your surgeon and team whether you should take OTC pain medications prior to your appointments. Your physician will assess your sinonasal symptoms and surgical recovery, perform physical exams like nasal endoscopy, and help to modify your medications accordingly.
What Are the Limitations after Surgery?
Your healthcare provider will provide specific information about limitations in activities after surgery. For example, you might expect to be out of work or school for about one week after surgery or until you are no longer taking any stronger pain medications. Heavy physical activity including lifting and bending at the waist might be avoided for two to three weeks to prevent an upsurge in bleeding or other problems. Sneezing with your mouth open may be recommended to avoid pressure building up in your nose and sinuses. You may also be asked not to submerge your head in water until cleared by your surgical team.
How Does the Extent of Surgery Impact My Healing after Surgery?
The type of surgery you have performed on your sinuses can change the time it takes to heal. Each time tissue or bone is removed, it creates a small wound that needs to heal, similar to a cut in your skin. These wounds heal by forming a scab that eventually falls off. Some cuts will go through the cycle of creating a scab and having that scab fall off and a smaller scab forming several times. A similar process will happen with wounds inside the sinus. When wide sinus openings are created, more wounds may be created that need to heal. If your surgeon needs to remove a large amount of diseased tissue, as may occur when polyps are removed, this can also create wounds that need to heal. The more wounds that are created during surgery, the more locations your body needs to heal, and this can add to the healing time. Your surgeon will describe the extent of surgery they recommend and discuss that healing process with you.
Will My Physician Provide Any Resources about Sinus Surgery for Me?
Most physicians will provide educational materials in paper and/or electronic format that include restrictions, important medications, and signs and symptoms that would warrant urgent evaluation during the post-op period.
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