Rao's ENTRao's ENT

Sinus Surgery (FESS)

Why is an endoscopic sinus surgery required?

An endoscopic sinus surgery is usually undertaken to bring relief from chronic rhinosinusitis (inflammation in nose and sinuses that’s unrelieved for at least 3 months) that’s not responding satisfactorily to medications. The cause of this inflammation can be anything from infection, allergies and irritants to polyps (non-cancerous swelling of the nasal/sinus lining). Actually, in quite a few cases, it is difficult to ascertain the root cause of rhinosinusitis.

Besides rhinosinustis, an endoscopic sinus surgery may also be undertaken to treat nasal polyps, impaired smelling sense, tear duct blockage, brain fluid’s leakage into the nose, recurrent infections (responding to medicines but making a comeback soon after), sinus infections affecting eyes, face or brain, or nasal and sinus cavity tumours of both benign and malignant types. However, these are the less common reasons. Actually, newest developments in the field have enabled sinus surgeons to open surgery pathways to brain and pituitary gland for neurosurgeries and to eye sockets for ophthalmic surgeries. As every individual and every illness has its own set of characteristic and requirements, it is for the sinus surgeon to determine if an endoscopic sinus surgery is your optimal option for relief from sinus/nasal affliction.

Endoscopic sinus surgery can be undertaken under local anaesthesia (only the body parts involved in the surgery are numbed) or general anaesthesia (the patient is under total sedation). The surgeon inserts a small device called a nasal endoscope into the patient’s nostril to observe the nose and the sinuses and identify the swollen narrow channels connecting the sinuses to the nose. The surgeon then widens these channels and their openings into the nose to boost drainage from sinuses into the nasal channel and thereby not just clearing the inflammation but also minimizing chances of its recurrence.

As has been explained in the diseases and conditions section, we have eight sinuses in our frontal skull (to see more on sinuses and their illnesses, visit https://www.raosentcare.com/sinusitis/ )

You may have sinusitis in all or some sinuses and the surgeon will assess which sinuses to open through a combination of diagnostic tools such as symptoms, physical examination, and CT scans. At times, this surgery can also include straightening of nasal septum and or turbinate reduction (to see more on nasal septum and turbinate surgery, please visit https://www.raosentcare.com/septoplasty-and-turbinate-surgery/ )

Another recent sinus treatment technique is to use ballooning to widen sinus openings. This can be done during the sinus surgery or as an in-office treatment depending on the patient and his/her condition.

Most likely, it will. Most patients treated with endoscopic sinus surgery witness significant improvement in their symptoms.

After the ENT surgeon has set a date for your endoscopic sinus surgery, you are advised the following precautions:

  • If you are on any prescription or non-prescription blood-thinning medications such as aspirin or ibuprofen, or similarly acting supplements such as omega 3, gingko or vitamin E, please consult your ENT surgeon well in advance to seek guidance on stopping and re-starting them.
  • Till the preceding night of the surgery, duly take all medications prescribed to you by the ENT surgeon. Bring along any remaining medicines in original packaging when you check in for surgery the next morning. Also bring along any non-prescription medications in their original packaging that you are currently taking.
  • Get a good night’s sleep. Have a good dinner but do not eat anything at all from midnight onwards prior to the surgery day.
  • Make sure you bring your hospital file with you at the time of the check-in for surgery duly including all required test reports such as the major surgical profile, pre- anaesthetic check up sheet, radiological investigation films and reports (X-ray, CT scan, MRI, PET scan etc.) and any others investigations advised by your ENT surgeon. We advise you to ready this file a day before the surgery.
  • You should be accompanied by an attendant. We advise bringing along a close family member.
  • Please ensure that you report at the hospital at least three hours prior to your surgery’s scheduled timing.
  • Report at the reception desk in time and the hospital staff will guide you through the next steps.
  • If you have felt any changes in your physical condition such as cough, cold, fever or throat pain, be sure to mention it to your doctor and anaesthetist. If you are allergic to any drugs, be very sure to mention that as well.

Please read the following information carefully to get further clarity on the pre-operative instructions including special instructions for patients with diabetes, respiratory or cardiac problems.

First 24 hours:

  • Take complete bed rest in the post-operation ward.
  • You are not allowed any drink or food till 4-5 hours after the surgery. After the surgical staff gives the go-ahead, you can sip water. A while later you can take milk or Horlicks etc. However, caffeinated beverages such as tea, coffee or aerated drinks are to be avoided as these can cause gastric irritation when consumed on an empty stomach. You can start a semi-solid diet in moderate quantities after 12 hours. You can resume normal food from second day onwards.
  • Your nose will be packed after the surgery for 1-2 days and you will have to breathe through the mouth. Before your discharge though, the hospital staff will remove this packing.
  • On the 10th day from the date of the surgery, you will receive an endoscopic nose cleaning in the Minor Procedure Room. Please plan your schedule to accommodate it.

After discharge:

  • You will be discharged either on the same day or the next day of your surgery, as deemed fit by the operating surgeon.
  • Be sure to take all medications on schedule as prescribed by your surgeon.
  • You will be prescribed nasal sprays (5-6 times daily in each nostril) starting from the day of discharge. Please ensure that you spray towards the side wall and not the centre of the nose always.
  • Till 2 weeks after the surgery, it is normal to have a ‘stuffy’ feeling in the nose that comes from the swelling caused by the surgery. Irritating though it may be, please do not:
    • Blow your nose
    • Breathe back forcefully
    • Probe the inside of your nose with finger

Any of the above can cause bleeding.

  • Till 2 weeks after the surgery, you will also feel dryness and lumpiness in the throat.
  • Till 2 weeks after the surgery, your nose will secrete blood-stained watery fluid. This is expected and simply needs to be gently wiped using a soft, clean cloth or tissue.
  • Do not rub or press your nose. Do not attempt to clean it from inside. Gentle cleaning from outside is permitted.
  • Stay away from places with dust, smoke, or anything that can cause an allergic reaction to induce excessive sneezing or watering of nose and eyes.
  • While normal diet is allowed, we advise you to abstain from cold foods such as ice creams and cold drinks or any other foods that can cause an allergic reaction to induce excessive sneezing or watering of nose and eyes.
  • If a sneeze comes, please open your mouth and sneeze out to protect the nose.
  • While regular body bath is allowed post the day of discharge, wait till your doctor gives clearance to have a head bath.
  • Protect your nose from pressure by abstaining from heavy lifting, straining, or undertaking any vigorous work for at least 3 weeks after the surgery. Also stay away from contact sports and any activity that can injure your nose.
  • Never bend your head below the heart level.
  • You can resume office work a week after the surgery. However if your work requires strenuous activity, we advise not resuming it till two weeks after the surgery.

Before endoscopic nose cleaning on 10th day after the surgery:

  • You can have breakfast.
  • Please take any medicines given to you specifically for the day of nose cleaning.
  • We advise you to be accompanied and driven to and from the hospital by a close relative. Your hospital procedure time (including examination and waiting) could be 4 hours approximately. Kindly plan accordingly.
  • Please report at the hospital at least 15 minutes before the scheduled time.
  • Please bring along any leftover medicines prescribed at discharge in their original packaging.
  • You can return to work after the endoscopic cleaning.
  • Mild bleeding from nose up to two days after the nose cleaning is normal. Please wipe using clean, soft cloth or tissue.

Outpatient review dates post endoscopic nose cleaning:

  • You will need to come for reviews twice – 10 days after endoscopic nose cleaning for the first review and 10 days after that for the second review.
  • If you suffer any problem in-between or after the reviews, please schedule a visit to the OPD of the hospital.

What to do if your nose starts to bleed:

  • Have someone help you. If you are alone, call a relative or friend to come and stay with you.
  • Do not bend your head. Do not lie down. Stay seated with your head in a normal upright position. Put a towel under your nose to absorb the blood.
  • Spit out any blood that drains down your throat.
  • Apply an ice-cold compress over the bridge of your nose. Dip and wring a cloth in ice-cold water to use as a compress.
  • Do the following as a first aid but only if your doctor has told you to – Apply pressure to your nose by pinching your nostrils tightly closed for 10 minutes. Repeat thrice for 10 minutes each time.

When to call the doctor:

Call your doctor immediately under any of the following circumstances:

  • If your nose does not stop bleeding in 5-10 minutes.
  • If bright red blood in heavy amounts is coming out of your nose.
  • If your body temperature is above 99.6 degrees Fahrenheit.
  • If your nose is draining excessively and you are sneezing a lot.
  • If pain medication is not able to dull your pain.

As with any other surgical procedure, endoscopic sinus surgery too comes with a few associated risks. While the odds of any complication arising are nominal, you should understand the potential risks and clarify your concerns from your surgeon well in advance.

  • Bleeding: Some degree of bleeding is expected in surgeries involving the nasal septum (the wall that divides the nasal cavity in two nostrils) or turbinates (intranasal structures that filter, warm up and humidify the air).  It is rare to need any other invention or to need a blood transfusion which is a rare and strictly an emergency measure in nasal surgeries. We have already mentioned it in the pre-operative precautions and remind you once more that you should consult your surgeon well in advance if you are consuming blood thinners such as aspirin and ibuprofen, or supplements such as omega 3, gingko and vitamin E, or if you need prescription blood thinners for another medical condition. Please get your surgeon to provide guidance on stopping and re-starting them before and after the surgery. Post-operative bleeding for the first 24 hours after the surgery is entirely normal but it can last for days, even weeks, in some cases.
  • Blood clot: If post-operative bleeding leads to a blood clot or hematoma within the septum, the surgeon will need to remove the clot which can cause scar tissue formation or even nasal collapse.
  • Voice changes: Sinuses’ role in the body includes lending resonance to the voice. Those in voice-related careers (VO artists, actors, singers etc) should be aware that an endoscopic sinus surgery can bring subtle changes in their voice.
  • Smell and taste impairment: An endoscopic sinus surgery usually increases the sense of smell by restoring better airflow. However in rare cases, sense of smell can weaken due to persistent swelling, allergy or infection. Most of the times, any impairment in senses of smelling or tasting is a temporary phenomenon but in a few cases, it may be prolonged.
  • Nasal obstruction, dryness and pain: Enlarged turbinates are often responsible for nasal congestion. Their size reduction in a surgery usually clears up this problem but in some patients, a sensation of high dryness can strike persistently. Some patients can even get chronic pain. In rarest cases, this can become a severe problem referred to as ‘the empty nose syndrome.’
  • Infection: A sinus surgery is mostly undertaken to resolve a chronic sinus infection that is not responding satisfactorily to medications. A sinusitis patient undergoing a sinus surgery is at risk of developing certain other infections such as abscesses or meningitis etc from sinus surgery. It may sound paradoxical but this is also a possible complication if the patient chooses not to undergo a sinus surgery for a severe or refractory chronic sinus infection.
  • Intraorbital complications (damage to the eye or surrounding tissue): The eye is in close proximity to paranasal sinuses and separated from them by a thin layer of bone. In rare cases, bleeding into the orbit can start that needs immediate treatment. In rarest of rare cases, this bleeding can even lead to blindness. Another rare problem is temporary or permanent damage to the muscles responsible for eye movement leading to double vision. Again in some rare cases, the function of the tear ducts can get upset and cause excessive tear formation. It may sound paradoxical but as the eye is in close proximity to the sinuses, these problems can occur even without surgery in patients with severe or refractory sinus infections.
  • Intracranial complications: As the top of the nasal septum is attached to the floor of the brain, a leak of cerebrospinal fluid into the nose can occur in case this thin bony layer breaks. It is a rare occurrence that the surgeon should identify and repair right there during the primary surgery. In rarest of rare cases, this problem can create a potential pathway for bleeding into brain, or infections such as meningitis requiring additional surgery and hospitalization.

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