Sinusotomy

Sinusotomy is a surgical procedure used to treat various diseases of the sinuses. Sinuses are paired spaces/cavities placed around the nose at the following locations:

• Frontal sinuses: Above the eyes, near the eyebrow region. 
• Maxillary sinuses: Underneath the eyes. 
• Ethmoidal sinuses: Between the eyes. 
• Sphenoidal sinuses: Behind the eyes.

The sinus cavities, especially the frontal sinuses, play an essential role in producing mucus (a slippery body fluid) that keeps the nose moist on the inside. This watery mucus is then emptied out through the nose. The whole mechanism assists in maintaining the hygiene of the nose while keeping it infection-free. Generally, sinuses are filled with air. However, under some conditions, fluid may gather inside them, which increases the risk of bacterial growth. Moreover, tissues of the sinus wall may get swelled up and inflamed, leading to a condition called sinusitis. Sinusitis can occur suddenly (acute) or over a longer period (chronic). Doctors usually suggest a few antibiotic medicines and decongestants to manage sinusitis. However, a sinusotomy is recommended if antibiotics do not help treat the condition.

During the procedure, a surgeon will either remove some cells of or the entire nasal portion of the frontal sinus floor.

Your healthcare provider may perform this surgery if you have the following conditions:

• Chronic rhinosinusitis (swelling in the mucosal wall of the nasal cavity with long-term symptoms)
• Tumours 
• Leakage of cerebrospinal fluid (CSF) (a colourless liquid in the brain and spinal cord that protects the central nervous system by acting as a shock absorber and carries waste material away from them)
• Acute sinusitis (rapid onset of swelling in the mucosal wall)
• Mucocele (fluid-filled swelling) inside the sinuses

Some of the symptoms of sinusitis are as follows:

• Fever
• Bad breath 
• Mucus inside the throat 
• Fatigue 
• A feeling of pressure on the face, especially, around the nose, eyes and forehead 
• Cough

A surgeon may not recommend sinusotomy if you have any of the following conditions:

• Aplastic frontal sinus (absent or incomplete development of the frontal sinus)
• A previous leak of CSF
• Splitting (dehiscence) or defect of the bone in the sinus region
• Osteomyelitis 
• Pott’s puffy tumours (swelling on the forehead resulting from osteomyelitis) 
• Large osteomas (bony growths/tumours usually occurring on the skull)
• Damaged area of tissue at the sides of the frontal sinuses

Before undergoing a sinusotomy, you will need the following preparations:

• Your doctor will review your medical history and conduct a physical examination for the correct diagnosis of the condition. He/she may also ask you to undergo a few diagnostic tests such as computed tomography or magnetic resonance imaging scan. Additionally, you may have to undergo blood tests, chest x-ray and electrocardiogram for the assessment of your overall health before the surgery.
• You should share a complete list of your current and previous medications with your doctor. This information includes prescribed and non-prescribed drugs, herbs, minerals, vitamins and supplements.
• Your doctor may prescribe an antibiotic and other medicines before the surgery.
• He/she may also suggest you to avoid consuming medications such as ibuprofen or aspirin that will increase your risk of bleeding during the surgery.
• Notify your doctor if the infection worsens before the surgery as the procedure may need to be postponed in such a case. 
• You will need to fast from midnight before and until after the surgery when your doctor permits you to eat. 
• You will be given a solution to spray on the inside of your nose one to two hours before the procedure. 
• Smoking cessation (or complete restraint) for at least three weeks before the procedure may help reduce the risk of complications after the surgery. 
• You will be asked to sign a consent form to give permission for the surgery. 
• Make sure to arrange for someone to drive you home after the operation.

After getting admitted to the hospital, you will get ready for the surgery by wearing a hospital gown. The medical staff will start an intravenous line in your arm to supply medications and/or anaesthesia. You will be given local or general anaesthesia before the surgery. General anaesthesia will be given through a tube inserted in your windpipe and will keep you asleep during the surgery. Local anaesthesia (a drug to numb the surgical area) will be given in the area of surgery along with sedative drugs to keep you relaxed but awake during the surgery. You will be lying on your back over the operating table during the procedure.

The two common approaches for the surgery are as follows:

Open or external approach: In this procedure, the surgeon may use various methods such as trephination and frontal sinus obliteration to treat the condition. 

The trephination procedure will be conducted as follows:

• The surgeon will make an incision over the area of your eyebrow. 
• He/she will use a drill or a chisel to access your sinus cavity and remove the excess fluid trapped inside it. 
• Next, the surgeon will insert a catheter (small tube) in the area to allow the residual fluid to continue to drain after the surgery.  
• Finally, the surgeon will close the skin around the catheter using sutures, and later remove the catheter when your sinus starts draining adequately.

The frontal sinus obliteration procedure will be performed in the following manner:

• The surgeon will make a cut in the front part of your head (coronal incision). 
• Then, he/she will open your sinuses with the help of a chisel and saw and remove the affected tissues of your sinuses. 
• The surgeon will remove the trapped/gathered mucus through your nose and use soft tissues and/or fat to fill in your sinus. 
• He/she will fix a wire or plate over the bone around the sinus and close the skin over the surgical site with the help of stitches.

Endoscopic approach: This procedure involves the use of an endoscope to visualize inside your nose. In this surgery, the following steps are performed:

• The surgeon will insert an endoscope through your nose. 
• He/she will place the endoscope near the diseased area and cut the extra bone or remove the swollen tissue as needed.

This procedure may take about 30-90 minutes. After the surgery, the surgeon may irrigate your sinuses with antibiotic medications through a catheter (tube) until you can pass the fluid through your nose naturally. Once this function is restored, the surgeon may remove the catheter. You may be sent home the day after your surgery.

After the surgery, you should care for yourself in the following ways at home:

• Medications: 
  • Your doctor may prescribe a few antibiotic medications to be taken for about five days after the surgery. You may also need painkillers to reduce post-surgery pain.
  • He/she may ask you to avoid medicines like aspirin for at least 7-10 days after the surgery. 
  • You must gently irrigate your nose twice daily after the operation. Your doctor may tell you the right way to do it. 
• Activities:
  • Avoid lifting heavy objects for at least 10 days after the surgery. 
  • Also, avoid bending or straining for two weeks. 
  • Do not suppress a sneeze or cough. Also, avoid forceful blowing through the nose or nose picking.
• Travelling: You should avoid travelling by plane for at least three to five days after the surgery. 

When to see the doctor?

You must notify your doctor immediately if you experience the following symptoms after surgery:

• Fever
• Changes in vision 
• Vomiting or nausea 
• Swelling in eyes 
• Stiffness in neck 
• Severe headache 
• Bleeding from nose

This surgery is known to carry the following risks:

• Bleeding 
• Leak of CSF 
• Urgent requirement of blood transfusion 
• Decreased sense of smell 
• Reaction to anaesthesia 
• Vision problems 
• Swelling, numbness or bruising around eyes and lips

The medical staff will schedule your follow-up one week after the surgery and regularly thereafter for wound check and debridement (cleaning the wound by removing dead or damaged tissue).

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.