Sinuses and Sinusitis

 

From ENT-UK website

 

What are sinuses?

There are four pairs of sinuses in the head that assist the control of temperature and humidity of the air reaching the lungs. Sinuses begin as pea-sized pouches in the newborn extending outward from the inside of the nose to the bones of the face and skull. They expand and grow throughout childhood and into young adulthood. Eventually they become air pockets or cavities that are lined with the same kind of lining that lines the nose. They are connected to the inside of the nose through smaller openings called ostia.

 

 

Normally the nose and sinuses produce a pint and a half of mucus secretions per day. These secretions pass normally through the nose picking up dust particles, bacteria and other pollutants along the way. This mucus is swept into the back of the throat by millions of tiny hair-like structures called cilia, which line the nasal cavity. The mucus moves into the throat and is swallowed. Most people do not notice this mucus flow because it is a normal bodily function.

 

 

Types of sinusitis

Sinus infection occurs in two types:

Acute sinusitis gives rise to severe symptoms but is usually short-lived. Acute sinusitis usually occurs following a cold. Typically a green-yellow nasal discharge occurs a week or more after the onset of the cold and this is associated with severe pain around the cheeks, eyes and/or forehead. This may be associated with swelling and a high fever along with toothache.

Chronic sinusitis is sinusitis that continues for many weeks. Chronic sinusitis may be caused by an acute sinus infection which fails to resolve or as a result of an underlying allergy affecting the lining membranes of the nose and sinuses. Common symptoms include nasal obstruction, headache, nasal discharge, low grade fever, reduced sense of smell, facial pain and halitosis.

 

 

What causes sinusitis?

It is worth noting that pain in the face may well be due to other causes such as tension headache, migraine, neuralgia and jaw dysfunction. The pain from sinusitis usually occurs as a result of blockage of the sinus opening. These blockages may be caused by infections, irritants, allergies or a structural abnormality.

Infections: Most adults will get colds and upper respiratory tract infections up to three times a year. Children get them more frequently. Bacterial infections often follow the common cold. When the mucus changes from clear to yellow or green it usually means a bacteria infection has developed. Both viral and bacterial infections cause swelling of the tissues inside the nose and thickening of the normal mucus. This slows down or even stops proper sinus drainage and infection in the sinus may ensue.

Irritants: Air pollution, smoke and chemical irritants, for example some sprays containing pesticides, disinfectants and household detergents, may cause swelling and blockage of the lining of the nose causing a narrowing of the drainage opening from the sinuses. This can once again lead to impairment of sinus drainage and consequent infection.

Allergies: Allergies can cause inflammation inside the nose. Common symptoms of an allergic reaction include nasal stuffiness, runny nose, sneezing and itchy watery eyes. Chronic sinusitis is sometimes associated with asthma. Allergies are responsible for asthma in some patients and may also cause nasal stuffiness making the asthma more difficult to control.

Structural problems: Occasionally structural problems within the nasal cavity can cause a narrowing. Some of these can be caused as a result of trauma while others may develop during the growth period. Occasionally the structural narrowing can be so severe that mucus builds up behind these areas of blockage giving rise to sinus infection.

 

 

Diagnosis and treatment of sinusitis

Acute sinusitis is usually treated with antibiotics and medication to reduce the swelling of the nasal lining e.g. decongestants. Chronic sinusitis may need long term treatment. Medical treatment options include antibiotics, decongestants and other treatments to reduce the swelling of the lining such as nasal steroid sprays. Antihistamines will have a place in patients who have an underlying allergy. In the vast majority of cases sinusitis can be managed effectively with medical treatment. 
Occasionally symptoms will persist despite ongoing use of medicines in which case surgery may be necessary. The diagnosis of sinusitis will involve the use of a nasal endoscope which the Mr. Chisholm can use to examine the nasal lining and the sinus openings.

 

 

Sinus surgery

Surgery is normally only considered if medical treatment fails. When surgery is needed the Mr. Chisholm can choose from a number of different options depending on the severity of the sinus disease. Most sinus operations are performed without an external incision. Mr. Chisholm will ask for a scan of the sinuses to assist with the planning of the operation.

 

What is endoscopic sinus surgery or FESS?

Endoscopic Sinus Surgery is the name given to operations used for severe or difficult to treat sinus problems. In the past sinus operations were done through incision (cuts) in the face and mouth but endoscopic sinus surgery allows the operation to be performed without the need for these cuts.

 

What if I don’t have the operation?

Endoscopic sinus surgery is only one approach to the treatment of sinusitis. Endoscopic sinus surgery is as safe, and possibly safer, than other methods of operating on the sinuses.

The other methods of operating on the sinuses involve cuts in the face or mouth and if you feel that this maybe more appropriate in your case you should discuss this with your surgeon. In some patients an operation can be avoided by use of antibiotics and steroid medicines, again this should be discussed with your surgeon.

 

The operation

Usually the operation is done with the you asleep (General Anaesthetic). The operation is all done inside your nose. Rarely there maybe some bruising around the eye but this is very uncommon. There should be no need for incisions (cuts) unless the operation is a complicated one in which case this will have been discussed with you before the operation.

 

After the operation

Immediately after the operation you may feel your nose blocked. This may be because of some dressing inside your nose or some special plastic sheets called splints. These are not used in every case but your surgeon will explain if they have been necessary in your case. Dressings , if used, will usually be removed from your nose within 24hrs but plastic splints may have to stay longer. It is common to have a stuffy blocked up nose even after removing the dressing or splints and this does not mean that the operation has not worked.

It is common for the nose to be quite blocked and to have some mild pain for a few weeks after the operation. This usually responds to simple painkillers.

It is important that you do not blow you nose for the first 48hrs following your operation. Mr Chisholm may recommend the use of drops, ointments and salt water sprays after the operation. You will be given specific instructions by the ward staff before your discharge from hospital. Some mucus and blood stained fluid may drain from your nose for the first week or two following the operation and this is normal. It is important to stay away from dusty and smoky environments while you are recovering.

 

 

How long will I be off work?

You can expect to go home on the day of your surgery or the day after your operation depending on the size of your operation. You will need to rest at home for at least a week. If you do heavy lifting and carrying at work you should be off work for at least two weeks.

 

Possible complications

All operations carry some element of risk in the form of possible side effects. There are some risks that you must know about before giving consent to this treatment. These potential complications are very uncommon. You should discuss with your surgeon about the likelihood of problems in your case before you decide to go ahead with the operation.

Bleeding is a risk of any operation. It is very common for small amounts of bleeding to come from the nose in the days following the operation. Major bleeding is extremely uncommon and it is very rare for a transfusion to be required.

Eye problems: The sinuses are very close to the wall of the eye socket. Sometimes minor bleeding can occur into the eye socket and this is usually noticed as some bruising around the eye. This is usually minor and gets better without any special treatment, although it is important that you do not blow your nose. More serious bleeding into the eye socket sometimes can occur, however this is very rare. This can cause severe swelling of the eye and can even cause double vision or in very rare cases loss of sight. If such a serious eye complication did occur you would be seen by an eye specialist and may require further operations.

Spinal Fluid Leak: The sinuses are very close to the bone at the base of the brain. All sinus operations carry a small risk of damage to this thin bone with leakage of fluid from around the brain into the nose, or other related injuries. If this rare complication does happen you will have to stay in hospital longer and may require another operation to stop the leak. On very rare occasions infection has spread from the sinuses into the spinal fluid causing meningitis but this is extremely uncommon. You can discuss this complication with your surgeon before the operation.

 

How often do complications happen?

In general, major complications are very rare. In a survey of all ENT surgeons who do this type of operation in England and Wales, eye complications happened in one in every five hundred operations, but there was no associated loss of vision. Spinal fluid leaks happened in one case in every thousand operations, but were detected and repaired at the same operation, so the risks are small. Minor complications, including bleeding from the nose occurred more often. One in four patients reported mild persistent bleeding after the operation, which resulted in readmission to hospital in some cases.

 

 

The management of sinusitis is perfectly outlined in the attached document:

European Position Paper on Rhinosinusitis and Nasal Polyps (a large .pdf file)

 

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