Sinus Surgery: Everything You Need to Know

Sinus surgery is used to clear obstructions and correct abnormal pathways in the sinuses so that you can breathe easier. It is an option for people with severe chronic sinusitis (sinus infections), atypical sinus structures, and growths in the sinus cavities.

Sinus surgeries are often complex, and procedures rarely involve just one sinus or one area of the nose. Instead, many structures are typically operated on using a variety of surgical techniques.

What Is Sinus Surgery?

Sinus surgery encompasses a variety of different surgical procedures that can be performed on their own or in combination. What's involved in your sinus surgery may not necessarily be the same as what's involved for someone else.

The list of surgical procedures used to treat sinus issues is extensive, and each surgery has a specific aim and purpose. The vast majority are endoscopic (using a narrow scope and tools to access the surgical site through the nostrils). Open surgery is less commonly pursued and is typically done for an infection that has spread to facial bones, the orbit (socket) of the eye, or the brain.

Among some of the most common procedures that fall under the umbrella of sinus surgery are:



Sinus surgery can be done on children and adults, typically by an ear, nose, and throat specialist known as an otolaryngologist (ENT) or an oral and maxillofacial surgeon who specializes in diseases of the face, head, jaw, and mouth. The procedure is also sometimes performed by an oral surgeon for dental purposes.

Sinus surgery is usually a scheduled procedure but may be done in an emergency if there is a severe nasal or facial fracture.

Surgery is typically performed as an outpatient procedure, allowing you to return home after surgery to recover. Depending on the procedures performed, the surgery may involve local anesthesia or general anesthesia.

Contraindications

Beyond general contraindications for any surgery, including active infection and a prior severe reaction to general anesthesia, there are conditions for which sinus surgery may be inappropriate. These can vary by the procedure performed.

Endoscopic sinus surgery is typically avoided—and treated with open surgery instead—in people with:

• Orbital abscess, a serious infection of the eye socket
• Pott's puffy tumor, an abscess caused by a bone infection called osteomyelitis

Endoscopic surgery in children under age 3 tends to be less successful and is often delayed until the child is older. In children under 6 who have severe sinusitis, adenoidectomy (the removal of the adenoids) is preferred over sinus surgery.

Certain open procedures, such as Caldwell-Luc surgery, are avoided in young children as well, as they may affect secondary tooth growth.

Potential Risks

As beneficial as sinus surgery can be to a person's health and quality of life, there are certain risks. In addition to complications associated with all surgeries, there are several that may occur with sinus surgery specifically, including:

• Facial numbness (often temporary)
• Teeth numbness or pain (often temporary)
• Severe nasal bleeding (sometimes requiring hospitalization)
• Anosmia, the partial or complete loss of smell
• Ageusia, the partial or complete loss of taste
• Septal perforation, the rupture of cartilage separating the nostrils
• Vision problems, including vision loss or double vision
• Cerebrospinal fluid rhinorrhea caused when a sinus cavity is ruptured, allowing cerebrospinal fluid to leak out of the nose
• Meningitis, a secondary inflammatory reaction caused when cerebrospinal fluid leaks into the cranium

Purpose of Sinus Surgery

The sinuses are an interconnected network of hollow cavities in the skull that are situated in the cheeks (maxillary sinuses), between the eyes (ethmoid sinuses), between the eyebrows (splenoid sinuses), and in the forehead (frontal sinuses).

Sinus surgery is typically indicated when conservative treatment options—including lifestyle changes like smoking cessation and the appropriate treatment of allergies (including allergic rhinitis)—have been exhausted.

Among the common indications for sinus surgery are:

• Refractory (treatment-resistant) chronic sinusitis
• Multiple recurrent attacks of acute sinusitis
• Nasal polyps
• Deviated septum
• Sinus mucoceles, cystic masses caused the accumulation of mucus
• Sinus pyoceles, cystic masses caused by the accumulation of pus and mucus
• Structural abnormalities of the ostiomeatal complex (the channels through which air flows between sinuses)
• Certain nasal and sinus tumors

Sinus surgery can also be used to biopsy masses for evaluation in the lab or for certain procedures involving the eye socket, including optic nerve decompression, orbital decompression, and dacryocystorhinostomy (used to create a new tear duct).

Preoperative Evaluation

If sinus surgery is indicated, a number of preoperative tests will be performed to map out the surgical plan. This is especially important as the sinuses are located near vulnerable nerves and blood vessels, including those that service the eyes.

The diagnostic workup may involve:

• Computed tomography (CT) scan: An imaging technique using multiple X-ray images that are then composited to create three-dimensional "slices" of internal structures
• Magnetic resonance (MRI) scan: An imaging technique that uses powerful magnetic and radio waves to create highly detailed images, particularly of soft tissues
• Nasal endoscopy: An indirect means of viewing the sinuses using a fiber-optic scope called an endoscope
• Rhinomanometry: A device that measures the flow of air and pressure as you inhale and exhale through the nose
• Nasal cytology: A test in which a swab of nasal mucus is cultured in a lab to check for potentially harmful bacteria or fungi
• Olfactory testing: A test used before and after surgery to detect notable changes in the sense of smell, typically involving the University of Pennsylvania Smell Identification Test (UPSIT)

How to Prepare

If sinus surgery is recommended, you will meet with your surgeon several weeks in advance to review preoperative tests and walk through the procedure step-by-step, including preoperative and postoperative care instructions.

Location

Sinus surgery is performed in the operating room of a hospital or specialized surgical center. The operating room is equipped with standard surgical equipment, including an anesthesia machine, a mechanical ventilator to deliver supplemental oxygen, an electrocardiogram (ECG) machine to monitor your heart rate, and a pulse oximeter to monitor your blood oxygen.

For endoscopic procedures, the surgical set-up would involve either a flexible or rigid endoscope connected to a live-feed video monitor. Endoscopic surgical tools specially designed to access the sinuses and either incise (cut), resect (remove), retract (separate), debride (scrape), suture (stitch), or cauterize (burn) tissues.

What to Wear

As you will be asked to change into a hospital gown, wear something you can get into and out of comfortably. Leave all valuables at home, including jewelry.

You will need to remove contacts, hearing aids, dentures, and nose piercings prior to the surgery.

Food and Drink

Even if local anesthesia is used, you may be advised to fast before surgery to avoid vomiting and the accidental aspiration of food into the lungs.

You are generally asked to stop eating at midnight the night before your surgery. The next morning, you are allowed a few sips of water to take any medications your healthcare provider approves. Within four hours of surgery, you cannot eat or drink anything, including gum or breath mints.

Medications

Because the nasal passages are populated with hundreds of tiny blood vessels, it is extremely important that you avoid certain medications that promote bleeding prior to undergoing sinus surgery.

Oral nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin, Advil (ibuprofen), Aleve (naproxen), Celebrex (celecoxib), and Voltaren (oral diclofenac) should be stopped up to two weeks before surgery. The same may apply to St. John's wort and high-dose vitamin E, both of which can interfere with blood clotting.

Similarly, anticoagulants (blood thinners) like Coumadin (warfarin) and Plavix (clopidogrel) are usually stopped five days before surgery.

What to Bring

You will need to bring your insurance card and a government-issued photo ID, such as your driver's license, to check-in to your appointment. You may also need an approved form of payment if the facility requires upfront payment of copay/coinsurance or procedure fees.

It is important that you bring someone with you to drive you home. Even if you only undergo local anesthesia, you may experience pain, watery eyes, and blurry vision after surgery, all of which can impair your ability to drive.

Preoperative Lifestyle Changes

If addition to stopping certain medications, your surgeon will recommend that you stop smoking at least 48 hours before and 48 hours after the surgery.

Smoking causes the extreme dilation of blood vessels throughout the body. When undergoing surgery, the abnormal dilation restricts the amount of blood, oxygen, and nutrients that reach the surgical wound, impairing healing while increasing the risk of treatment failure.

If you think you'll have trouble quitting cigarettes, discuss the option of using smoking cessation aids with your provider. Many are fully covered by insurance under the Affordable Care Act and may end up costing you nothing.

Other Preparations

Prior to surgery, your surgeon may recommend that you purchase a decongestant nasal spray like Afrin (oxymetazoline) to use immediately before surgery. An isotonic saline nasal spray may also be recommended for use immediately after surgery.

Both can be purchased over the counter at most drugstores.

What to Expect on the Day of Surgery

On the morning of your surgery, you may be asked to wash thoroughly with an antiseptic surgical wash. Do not apply makeup, lotion, ointments, or fragrance after showering or bathing.

If you have an especially thick mustache, you may want to trim it neatly prior to your arrival. You do not need to shave your facial hair completely.

If a decongestant spray was recommended, your healthcare provider may instruct you to take a dose one to two hours before surgery to help dilate nasal tissues and provide easier access for the endoscopic tools.

Try to arrive 15 to 30 minutes before your scheduled appointment to fill out the necessary forms and have a moment to relax before surgery.

Before Surgery

After you have checked in and signed the necessary consent forms, you will be led to change into a hospital gown.

Your nurse will then take your vital signs as well as a sample of blood to check your blood chemistry (particularly if general anesthesia is to be used). To monitor your heart rate and blood oxygen saturation, ECG probes are attached to your chest and a pulse oximeter is clamped to your finger.

An intravenous (IV) line is inserted into a vein in your arm to deliver anesthesia, medications, and fluids.

During Surgery

Once you have been prepped, you are wheeled into surgery and placed on the operating table in a supine recumbent position (face-up, on your back). Many endoscopic surgeries are performed with your chin slightly raised and the back of your neck bolstered with a cushion. For open surgeries accessed through the mouth, the head may be tilted slightly forward.

Depending on the surgery, you may be given local or general anesthesia. Local anesthesia, delivered by injection to numb the surgical site, is often accompanied by a form of IV sedation called monitored anesthesia care (MAC) to help you relax and induce "twilight sleep." General anesthesia is delivered intravenously to put you completely to sleep.

The approach for surgery varies by whether it is endoscopic or open.

Endoscopic Surgery

The surgical site is prepped with an injection of lidocaine (a numbing agent) and epinephrine, both of which help further widen the sinus passages. The surgery is performed entirely through the nostril, directed by live-feed images on the video monitor.

In some cases, the tissue between the nostrils, called the columella, will need to be cut to provide better access to the surgical site.

Once completed, a dissolvable spacer may be inserted to keep the air passages in the intended position. The nostril may also be packed to stem bleeding. Nasal tubes may or may not be inserted.

Open Surgery

Open sinus surgery is most commonly accessed through the mouth by lifting the lip and cutting a hole in the bony plate just above the teeth. This provides direct access to the maxillary sinus.

Once the repairs are complete, the incision is stitched with dissolvable sutures, usually without filling the hole.

After the Surgery

After the surgery has been completed, you are wheeled to the recovery room and monitored until you are fully awake from the anesthesia. It is normal and not uncommon to feel pain or pressure in the middle of the face as well as dizziness or congestion.

Once your vital signs have normalized and you are able to change back into your clothes, you can leave under the care of a friend or loved one. Pain medications may be prescribed, and you will be given detailed wound care instructions to follow.

Recovery

After sinus surgery, it is normal to experience pain (usually a headache or a slight burning sensation in the mid-face region), nosebleeds, and bad breath for the first 24 to 72 hours. Less commonly, you may develop a black eye or have temporary numbness or tingling in the face or gums.

For the first day or two, take it easy and avoid any unnecessary movements. To keep the nasal passages well humidified, your healthcare provider may advise you to use a saline nasal spray every three to four hours.

If you have had open sinus surgery through the mouth, you can brush and floss as normal, but avoid the treated area. Gently rinse with an oral antiseptic three times daily to avoid infection.

Most people can manage postoperative pain and swelling by elevating the head with pillows when lying down, taking an analgesic pain reliever like Tylenol (acetaminophen), or placing a cold compress on the face for no more than 10 to 15 minutes several times a day. NSAIDs should be avoided as they can slow wound healing and increase the risk of nosebleeds.

Healing

The recovery time from sinus surgery can vary by the procedure, but most patients need about one or two weeks before they can reasonably return to work or normal activities. For some surgeries, full recovery may not be achieved for three to four months.

During the recovery period, there are several things you can do to aid with healing:

• Irrigate your sinuses twice daily. Once the nasal tubes have been removed, you can irrigate the sinuses with either a saline rinse squeeze bottle from the drugstore or use a neti pot with a sterile isotonic saline solution.
• Treat nosebleeds. Nosebleeds are common after sinus surgery and can usually be treated by pinching the nostrils just above the bridge of the nose until the breathing stops. If the bleeding doesn't stop, a spray of Afrin often helps.
• Avoid steroid or antihistamine nasal sprays. Steroid nasal sprays can impede healing, while antihistamine sprays can dry nasal passages. Both should be avoided for two weeks following sinus surgery. The same may apply to continuous positive airway pressure (CPAP) machines used to treat sleep apnea.

While it is normal to have a thick white nasal discharge (usually mucus) or a pinkish/brownish nasal discharge (caused by blood) after a single surgery, other kinds of discharge may be a sign of infection. Postoperative infections are uncommon but can occur.

Follow-Up Care

Depending on the procedure, your surgeon will schedule a follow-up appointment within one to two weeks to check how your wound is healing. A CT or MRI scan may also be ordered.

Since it can take months to fully heal from sinus surgery, you can expect to have one or more additional appointments. Repeat scans may be ordered as well as a repeat olfactory test to check if there is any loss (or improvement) of smell.

Though sinus surgeries are able to improve or fully resolve symptoms in 80% to 90% of cases, up to 20% may experience a recurrence of symptoms at a later date. Revision surgery is often needed in such cases. Unfortunately, there is really no way to tell in advance who may or may not experience recurrence.

A Word From Verywell

Most of us think of sinus surgery one thing, but it is actually a plethora of surgical techniques that, alone or together, can resolve chronic sinus conditions when all other treatments fail.

Before pursuing sinus surgery, ensure that you have explored every reasonable non-surgical treatment option.