Dr Ralph Stanley from Stanley ENT and Sinus Centre speaks on surgery for the treatment of sinus problems. Part 4 of 4 mini-series in Up Close With.
Dr Ralph Stanley from Stanley ENT and Sinus Centre speaks on anti-histamines, intra-nasal steroid sprays and dust-mites allergy in sinus problems.
Dr Ralph Stanley from Stanley ENT and Sinus Centre explains how sinus problems are evaluated with endoscopy and CT scans in part 2 of 4 mini-series in Up Close With.
Dr Ralph Stanley from Stanley ENT and Sinus Centre explains the types and causes of sinus problems in part 1 of 4 mini-series in Up Close With.
What is Functional Endoscopic Sinus Surgery (FESS)?
This article is contributed by Dr Kelvin Soh (Mt Elizabeth ENT Surgeon)
The sinuses are air filled spaces in the skull. Most people do not realize these spaces exist in the skull until a problem develops, and they begin to experience the symptoms of sinusitis.
There are 4 pairs of sinuses one pair over the cheeks (maxillary), forehead (frontal), between the eyes (ethmoid), and a last pair deep in the center of the head (sphenoid). The sinuses are connected to the nose and nasal cavity by way of small openings called ostia.
Except for the ethmoid sinuses between the eyes, the other sinuses are poorly developed at birth. They normally commence development in later
childhood to attain their adult size at the onset of puberty. This means that if a young child gets sinusitis, it mainly involves the ethmoid sinuses located between the eyes.
Individuals who do not have a particular sinus will not develop sinusitis in that area. For example, 10% of people in the general population have poor development of the frontal sinuses. This makes it impossible for them to suffer from the excruciating headaches of frontal sinusitis.
Sinusitis often starts off as a flu
A patient of mine, Mr. Tan, first realized how troublesome sinusitis can be when he first contracted the infection 2 years ago. The symptoms first started as a flu, which caused blocked nose, runny nose, and pain over the cheeks. The pain got worse, and reached a crescendo 3 days later, when it was so painful that he was unable to go to sleep. He would wake up in the mornings feeling that he had not slept at all. The pain in the cheeks had also extended to involve the forehead, and the top of his head.
By this time, his nose was so blocked that he had to open his mouth to breathe. He would wake up the next day with a very dry and sore throat. Furthermore, he could not enjoy his meals as his sense of smell and taste had been affected.
Initially he thought that the symptoms would go away in a week. However, when the symptoms continued to persist, and his ability to work was affected, Mr. Tan became desperate.
Over the next few months, he consulted many doctors and was given a myriad of different medications. He even sought treatment from several Chinese traditional physicians without benefit. Finally, one of the doctors he consulted had the wisdom to perform an endoscopic examination of his nose, and discovered that his sinus openings were blocked by swelling.
He went through a computed tomographic scan (CT scan) which showed that he had sinusitis of both his maxillary and frontal sinuses.
Sinus surgery was performed under general anesthesia.
One week later, his symptoms of pain, sorethroat, and inability to smell had disappeared. Since then, he has been enjoying very restful and peaceful nights of sleep.
Fortunately, many people suffer from sinusitis, but few need surgery for resolution of their symptoms. Most sinusitis can be treated with medications like antibiotics, decongestants, and antihistamines.
Allergy, structural deformity, cancer and nose polyps cause sinusitis
Allergies cause up to 80% of cases of sinusitis. The allergic reaction causes the lining of the nose to become inflamed and swollen (rhinitis), resulting in obstruction of the sinus ostia, and poor drainage of the sinuses.
Secretions build up, providing a good growth medium for bacteria, allowing them to flourish in an unimpeded fashion within the sinuses. Pus forms and accumulates under pressure, allowing some of it to squeeze and escape through the narrowed ostium into the nasal cavity. This gives rise to the yellow nasal discharge that is seen in sinusitis.
Sinusitis can have a variety of other causes. The common final pathway by which all these other diseases cause sinusitis is through obstruction of the sinus ostia resulting in poor sinus drainage. Thus, deviation of the nasal septum, foreign bodies, cancer, and nasal polyps can cause obstruction to the sinus ostia, giving rise to sinusitis.
Improving sinus drainage with Endoscopic Sinus Surgery
In those patients who are unable to benefit from medications, surgery is needed.
With modern technology, we are now able to perform minimally invasive key-hole surgery on the nose and sinuses.
Endoscope: The endoscope enables us to make more accurate diagnosis of the causes of sinusitis, and to identify new disease processes which could not have been identified before. It has also enhanced our ability to perform sinus surgery by peering through the nostrils instead of having to make unsightly facial incisions.
Microdebrider: The microdebrider is a surgical instrument that simultaneously vacuum-sucks and trims. The trimmer chops off unwanted abnormal tissues, while the vacuum suction clears away unwanted debris and blood from the area of operation. The vacuum microdebrider improves precision during surgery.
Computer navigation: This improves safety by helping the surgeon avoid danger areas like the brain and eye.
Surgeons, like pilots, need good navigation. Occasionally, in complex sinus operations, surgeons may get lost in the surgical wound. They may not be able to identify with confidence the location of important structures, like the optic nerve, carotid blood vessels, nasolacrimal duct, and base of skull. In these instances, computerized navigation instruments are available to lend a guiding hand.
Computer navigation is particularly useful if the anatomical structures in the sinuses are distorted by developmental factors or previous surgery. It gives the surgeon more confidence in charting his course within the complex labyrinth of the nose and sinuses.