Have you ever asked your doctor or just sign in consent?
Nose or Sinus Surgery in medical terms indicates enlarging the paranasal sinuses and nasal drainage pathways to improve sinus ventilation and allow access to topical medications. It restores the normal function of the sinus without the destruction of normal mucosa. In layman terms, sometimes sinus surgery is also known as surgical treatment to improve nasal block due to allergy or non-allergy components. It is understood as surgery involving the turbinates and septum in general.
In this article, I would like to highlight the concept of sinus surgery as being understood by the general population. No matter what surgery is done to address the pathology in the nose and sinuses, it should apply to the concept of mucosal preservation except in tumor-related or cancer-related cases. If you are going to see a doctor to have your nose and sinus job done, these are the four most crucial queries or prerequisites before you consent.
Nose or Sinus Surgery – Four crucial questions to ask before you go for your nose or sinus surgery:
- What type and method of surgery are being used?
Knowing what type of surgery and what method will be used should be of the utmost importance. This is because you wouldn’t want to end up with a total disastrous outcome post-operatively, especially in the long term. The nose is one of the most important organs that we use in everyday life, and you will regret the rest of your life if there is a sinister complication associated with the methods used. The concept of nose surgery is mucosal preservation. The mucosa of the paranasal sinuses and nasal turbinates is highly specialized, with known functions including mechanical clearance of toxins and foreign matter, nitric oxide production, and cellular and humoral adaptive immune responses. The mucosal layer of the turbinates is an essential immune-system organ, providing the first line of defense against inhaled bacteria and other pathogens. Through host defense peptides and other effectors of innate immunity, the mucosal layer of our turbinate epithelium maintains a population of harmless bacteria that helps keep out dangerous bacteria from entering the nose. Before we discuss further, let me briefly mention the anatomy of the nose.
The inferior turbinate is a sausage-like bony structure that lies along the sidewall of your nose (one on each side of the nasal cavity). A layer on top of the bone is mucosa which I mentioned earlier. Commonly done surgery to resolve nasal block or at times known as turbinoplasty, turbinectomy, or trimming of turbinate (TIT). The surgical technique of inferior turbinates surgery against mucosal preservation is resection involving long narrow scissors cutting the whole turbinates ( mucosa, submucosa, and bone) to improve the nasal airway, also called turbinectomy or TIT. Somewhere along the way, the goals and expectations of surgery have been forgotten. You may ask what’s wrong with the removal of turbinates, it provides no blockage in the nose and breathes better?
Well, you actually can’t feel the air moving in your nose because the turbinates have been cut off, and you’ll feel a sensation of suffocation and emptiness. It is called ENS( empty nose syndrome). With over-aggressive resection of these turbinate structures, particularly with resection of the mucosal layer of the turbinates, people with ENS lose the ability to feel their nasal breathing. Patients with ENS lose these regulators of bacterial homeostasis, and dangerous and harmful bacteria slowly colonize the nose. These bacteria can cause crusting, bleeding, worsening nasal congestion, and worsening dryness and desiccation of the remaining nasal lining, leading to a vicious cycle and worsening the symptoms associated with ENS. Unfortunately, there is no quick fix or easy treatment for ENS. Another bad technique is superficially destroying the mucosa with ablation or coagulation, electrocautery.
The best technique is turbinoplasty or volume reduction surgery of turbinates using ablation over submucosa and not mucosa. There are many methods of volume reduction turbinoplasty, such as coblator, laser, microdebrider, and radiofrequency. The submucosal will scar, and fibrosis later shrinks the turbinates while preserving mucosa. We have advocated this method for many years, and this produces excellent surgical outcomes without ENS as it is evidence-based supported by many latest journals.
- Which sinuses of mine are affected, and which ones are you going to operate on? Which of my symptoms can be improved by sinus surgery?
There are four main sinuses: ethmoid sinus, frontal sinus, maxillary sinus, and sphenoid sinus. As for FESS (functional endoscopic sinus surgery) for sinusitis, we would prefer to address the related sinus and not unnecessarily expose bones in the nasal cavity. Mucosa must be preserved as much as possible. As the name mention, ‘functional’ means to restore the normal function of sinuses. Ct scan is essential to identify abnormality of sinuses and height of the base of the skull before surgery. The first line of treatment of chronic rhinosinusitis is medical therapy. This includes antibiotics, oral steroids, nasal irrigations, and topical nasal sprays. Failed medical therapy would be indicated for sinus surgery. I always prefer to discuss with the patient the surgical plan to maximize postoperative outcomes. Diseased tissues and a small fragment of bone will be open to ventilate the sinus cavity.
The majority of people in Malaysia come for surgery for symptoms of allergy and not sinusitis. Symptoms of sinusitis such as facial pain, foul smelly discharge, headache, and retro-orbital pain can be resolved with sinus surgery but not allergic symptoms. Allergic symptoms such as rhinorrhoea, nasal congestion, eye itchiness, and sneezing will not recover after FESS. However, adding on turbinoplasty and septoplasty may resolve nasal blocks and deviation of the septum.
- What are risk factors and complications?
Knowing risk factors and complications with ensuring mental preparedness for surgery. This is not making you worry but preparing for possible related complications. Complications tend to happen even if surgeons are cautious due to many unexpected circumstances. However, the risk of surgery is very minimal. Nevertheless, any surgery carries possible risks and complications. Therefore, a physician should inform the patient before surgery because potential complications may happen, although the chances are rare. Common complications in sinus surgery are:
- The bleeding risk in FESS & septoplasty is low. Significant bleeding can be halted with ligation of the supplying vessel. However risk of bleeding in turbinectomy is higher compared to volume reductions surgery, aka turbinoplasty
- Infection can be easily treated with antibiotics. Manipulation of native tissue carries a risk of infection
- Visual impairment. The three sinuses surrounding orbit are ethmoid, frontal, and maxillary sinus. The ethmoid sinus is separated with paper-thin bone known as lamina papyracea. Instrumentation will carry a risk of fracturing this thin wall and causing hematoma of optic nerve injury.
- Cerebrospinal fluid leakage is the presence of fluid dripping down from the nose
- Medications or herbal remedies and habits which need to be avoided?
Some herbal medications the patient takes will cause bleeding tendencies. It is essential to avoid these remedies at least one month before surgery. Chinese herbal medicines, including ginseng, ginkgo biloba, ginger, sal palmettored dates, and certain types of mushrooms, will result in intra/post-operative bleeding. Furthermore, smoking should be stopped two weeks before surgery to hasten healing and improve mucociliary clearance. Smoking is known to increase the risk of anesthesia and affect post-operative healing. Certain medications must be avoided at least one week before surgery, such as warfarin, aspirin, Plavix, coumadin, and NSAIDs.
In conclusion, do understand what will be done to your nose before you consent for surgery as this would be disastrous after surgery due to potential complications and lifetime problems of empty nose syndrome.