Sinus Problems – Even After Surgery
Originally Published 1999
This section is written primarily for those patients who have had endoscopic sinus surgery and despite surgery, symptoms have continued. We will not address the immediate post-operative complications as those should be satisfactorily addressed by the Otolaryngologist and can include such things as excessive bleeding, infection, perforation into the brain or eye, etc. This time generally extends up to approximately 3-6 weeks after surgery.
Basic principals of treatment after surgery are essentially same as the pre-surgical treatment: To ensure adequate drainage from the sinuses. It is unrealistic to expect that surgery will cure sinusitis, as the same processes which occurred prior to surgery will continue afterwards. Surgical treatment simply allows the sinuses, which previously did not drain, to drain through the ostia.
Once adequate drainage has been provided, it is often possible to forgo use of oral antibiotics by providing copious irrigation with an antibiotic such as Gentamycin in a saline solution to irrigate out the sinuses. It is often necessary to continue mucous thinners as well as steroid nasal sprays depending on the appropriateness of the circumstances. Irrigation with the Grossan Nasal Irrigator can also prove helpful under those circumstances.(A link to this website will appear as a pop-up window.)
Proper technique for using irrigation must included adequate amounts of saline to ensure that the sinuses are thoroughly irrigated.
Excessive crusting is a not uncommon problem in post-surgical patients. In those cases surgical debreedment, mucous thinners, an increase in humidity level, frequent use of salt water nasal sprays and irrigation may be helpful.
Anti-inflammatory drugs will sometimes reduce inflammation in patients, but must be carefully chosen in patients who are aspirin sensitive and have the combination of nasal polyposis, asthma and aspirin sensitivity. It is important to remember that all drugs in the aspirin class such as Motrin and Aleve will cause the same problems.
Occasionally, intranasal steroids can cause inflammation, in which case management may include decreasing the dosage, eliminating steroids, or using a weaker steroid and possibly adding an oral steroid.
Patients who are allergic must be carefully evaluated as even minor allergies may cause enough of an exacerbation of chronic sinusitis to cause dramatic worsening in symptoms. In addition to environmental controls, allergy immunotherapy is often used to manage these patient. It may take an extended period of time for immunotherapy to provide adequate treatment, however.
Patients who are on allergy immunotherapy must be evaluated to make sure that adequate dosages and adequate numbers of antigens are used in treatment. Due to the effects of Managed Care, some patients may not get adequate numbers of antigens because of cost and re-imbursement issues.
Selected patients have found that a variety of unorthodox treatments as listed in the treatment section may occasionally be helpful, but it is difficult to tell if this is due to a placebo effect. They must be viewed with a certain degree of skepticism, however if they work for a patient who has failed all other forms of therapy, one cannot dismiss them. Several patients have found that using a new Papaya enzyme formulation called ClearEase may be helpful. It is made by Dr. Grossan.
It is speculated that some patients may have worsening of sinusitis due to food or stomach acid refluxing or repeating i.e. coming up from the stomach into the esophagus and sumbsequently into the back of the mouth. It is unclear whether it is possible for it to actually get into the sinuses. It is diagnosed by putting a tube into the esophagus to check the amount of acidity. Treatment is with acid blockers (Zantac, Axid, Tagamet, Pepcid, Prilosec or Prevacid.)
Any patients with chronic sinusitis, which is poorly responsive to treatment, should have an extensive immunological evaluation including immunoglobulin levels, possible IgG subtypes, and antibody testing. Pneumococcal, diphtheria, and tetanus antibodies should be tested before and after Pneumovax and diphtheria/tetanus immunizations. Evaluation should be done by an immunologist familiar with testing as results can be difficult to interpret. Briefly, 12 different subtypes of the pneumococcal antigen should ideally be tested with an adequate rise in the antibody titer to determine that the patient has responded to the vaccine. In cases where an immunodeficiency is found, monthly immunoglobulin (IVIG) therapy may need to be initiated. Selected patients may occasionally warrant IVIG despite normal antibody levels. Such patients must be selectively chosen by experienced clinicians, as IVIG is extremely costly.
Children should be evaluated for cystic fibrosis. Selected patients may need to be evaluated for HIV disease.
Some patients operated on by inexperienced Otolaryngologists may not have adequate surgery performed. If the uncinate process is not removed recurrence of symptoms is common. Some patients also may not have adequate amounts of ethmoid air cells removed. This is one of the reasons that an experienced endoscopic surgeon must be selected. Occasionally, instead of a single ostium into the maxillary sinus, there can be two created which can cause re-circulation of mucous, (in one ostium and out the other). This can lead to continued symptoms and may necessitate further revision surgery.
Various ‘new techniques’ have been espoused including laser, etc., but essentially all must be used in conduction with traditional endoscopic sinus surgery in order to provide optimal results. One must be wary of surgeons who suggest minimal procedures such as repair of a deviated septum and turbinate reduction when endoscopic sinus surgery must also be done. All too often patients may have procedures done which do not involve resection of an obstructed ostium, and they have continued symptoms.
Frontal Sinus Disease
Periodically, frontal sinus disease will persist after surgery is done on other sinuses. Usually frontal sinusitis will resolve without surgery, however occasionally persistent disease will require operative intervention. Previously it was difficult to perform frontal surgery due to the thickness of the bone in the area which must be resected, however with the new image guided techniques, in many cases it is possible to operate on the frontal sinuses without using the traditional procedure which involves obliterating the frontal sinus by folding down a flap of forehead skin over the eyes to allow visualization of the bone in the forehead and then cutting a hole in the forehead bone to allow a complete clean out of the frontal sinuses. The frontal sinus is then filled with fat so that the sinusitis won’t reoccur.
Patients who have recurrent disease also must be evaluated for allergic fungal, invasive fungal disease, and fungus balls. Treatment of this is discussed in the section for physicians.
Once surgery has been done, it is much easier to do cultures to determine if an unusual bacteria or fungus is involved. It is possible to direct the culture into the involved sinuses at the time of endoscopy.
Some patients who have not responded to surgery may need to get outpatient treatment with intravenous antibiotics for 6-8 weeks to clear up infection which persists after surgery. Sometimes the intravenous antibiotics will also be given before or instead of surgery as well. The exact antibiotics will be determined by the doctor.
Some patients will develop new areas of sinusitis post-surgically which may or may not be able to be visualized on endoscopy and sometimes require repeat CT scans. In those cases, oral antibiotics are more likely to be necessary and in some cases surgical revision either done in office or with hospitalization may be necessary.
Not all scarring necessarily needs to be removed. Fastidious post-operative care can typically reduce the incidence of scarring. Recurrent nasal polyposis is not uncommon in patients with chronic sinusitis. The etiology of nasal polyposis is not clearly established, but it is felt to be related to chronic inflammation. In some cases, extensive polyposis may require further surgical revision, although often with good medical management, including oral or nasal steroids, it may be possible to avoid surgical intervention.
Rarely, it may be necessary to perform a ‘Lynch’ procedure on the ethmoid sinuses. This involves making an incision on the side of the nose extending down from the eyebrow in a semi-circle to allow more complete resection of the ethmoid sinuses. With the advent of image-guided surgery, it is often possible to avoid this procedure which is more disfiguring than the usual endoscopic surgery
There have been selected reports in patients who have nasal polyps and sinusitis that they may respond to the anti-leukotriene agents (Accolate, Zyflo, and Singulair) (discussed in the asthma section). The makers of Ocean are advocating the use of Singulair dissolved in Ocean as a treatment for nasal polyps.
It is critical that patients be evaluated for outside agents which may exacerbate sinusitis. As stated elsewhere, tobacco smoke causes paralysis of the cilia and must be avoided if one is to hope to treat sinusitis adequately. The same applies for marijuana smoke. Alcohol can also cause dehydration, forgetfulness concerning medications, and in some cases allergy. We have found that patients on virtually all antidepressants as well as antihistamines can have an excessive amount of dryness in the sinuses and become symptomatic as a result. A report by Dr. Steinsvag from Norway suggests that a preservative called benzalkonium chloride, which is contained in almost all AQ formulations of nasal spray may cause loss of cilia from the nose. It is also in Ocean and Ayr. Whether it can cause worsening of nasal symptoms is unclear at this time.
We often suggest that patients start on preventive treatment at the first sign of developing upper respiratory symptoms. These treatments include irrigation, nasal steroids, mucus thinners, decongestants, zinc gluconate lozenges, steam vaporizers, etc. As stated previously, it is often possible to avoid antibiotics.
Post surgical management in patients who have not responded to surgery can be extremely difficult for most doctors to perform, as most physicians do not have extensive experience with this kind of patient. As stated elsewhere, it is difficult for many physicians to treat patients with chronic sinusitis, but this is doubly important in patients post surgery, as you must find physicians with extensive experience in such treatment in order to provide optimal care.
© 1998-9 by Wellington S. Tichenor, M.D.
Dr Tichenor is in private practice in New York City. We recommend his web site highly. It is one of the most authoritative and content rich sites on the web we know.
Please note that all advice here is general: all patients in a doctor’s care must consult their doctor regarding the use of our products. The use of these products is NOT a substitute for seeing your doctor for any potentially serious medical condition.