Nasal & Sinus Institute


PARANASAL SINUS ANATOMY

The anatomy of the paranasal sinuses is complex.  The black and white image above is from a type of x-ray called a Cat Scan of the sinuses, and is commonly used by sinus surgeons.  Roughly speaking, bone is white, soft tissue or infection is grey and air is black.  The sinuses should have nothing in them except for air.  The sinuses are mucosa-lined structures are located adjacent to the nasal cavity, brain, and orbits.  There are multiple compartments including: the maxillary sinuses located near the cheek region, the frontal sinus found in the forehead area, the ethmoid sinuses between the eyes and lastly the sphenoid sinus which is found deep behind the nose.

PATHOGENESIS

Most commonly, sinusitis occurs as a result of inflammation and infection of the membranous lining of the sinus. This causes the membrane to swell and the sinus openings to narrow resulting in the blockage of mucous movement. The accumulated mucus can then lead to an eventual infection.  The maxillary sinus ostium is seen in the x-ray image above needs to stay open to allow the maxillary or cheek sinus to function.  If inflammation causes this thin opening to close, a sinus infection can develop.  An abnormal gland called a concha bullosa (Latin for air-filled shell) or a posterior deviation of the septum (often overlooked by other nasal surgeons) can make the area around the ostium more crowded and more likely to develop disease.  Correcting these areas of anatomic abnormalities is crucial to achieving success in sinus surgery.

On rare occasions, nasal and sinus congestion may be due to sinus tumors either benign or malignant.  The majorities of the masses found in the nasal cavity and sinuses are benign and not malignant (cancerous).  Hence, it is of the utmost importance to be fully evaluated by a specialist.

SIGNS & SYMPTOMS

Sinusitis can cause facial pain/pressure, nasal obstruction, nasal discharge, decreased sense of smell, and cough from post-nasal drip.  Other symptoms can also include fever, halitosis, fatigue, tooth pain, and headache.  The condition can last four weeks or more.  If left untreated the symptoms can become chronic and cause complications.  As seen in the Cat Scan above, the maxillary sinus and the ethmoid sinuses are now grey, indicating the presence of abnormal soft tissue or infection.  In the photo above, yellow pus is seen coming out of the ostium area (called the middle meatus).

DIAGNOSTIC TECHNIQUES

Having an on-site Computed Tomography (CT) Scanner allows our surgeons to diagnose and tailor individual treatment plans in an expedited fashion.  This prevents delay in treatment.  In addition, using the newest equipment, our surgeons are able to directly visualize the nasal passage with an endoscope in our office.   A complete physical exam and evaluation will be performed.   The above scopes often are used to perform a thorough exam.  Don’t worry- we use spray anesthesia to make the scope insertion comfortable.

When we suspect we are working with a sinus tumor or base of skull neoplasm, further work up with an MRI or MR angiogram is needed.

MEDICAL TREATMENT

Antibiotic for ten to fourteen days is the usual treatment for sinusitis.  Other treatments including oral and topical decongestants, nasal steroid sprays, antihistamines, and nasal saline irrigations can help alleviate the symptoms as well.

By the time most of our patients have reached us, many or all of these modalities have been tried.  Many times inappropriate antibiotics have been prescribed.  Whether the patient has had surgery or not, by reviewing prior medical therapy, we can find areas for improvement.  For example, using appropriate antibiotics or targeted dual antibiotic courses are at times beneficial and necessary.   Many patients do better on allergy immunotherapy and /or leukotriene inhibitors.

SURGICAL TREATMENT

Functional Endoscopic Sinus Surgery (FESS)
When patients have failed medical management, have nasal polyps, or continue to have recurrent symptoms, Functional Endoscopic Sinus Surgery (FESS) is the next step. The goal of the surgery is to enlarge the openings that drain the sinuses.  An improvement in symptoms of up to 90% may be expected following the procedure, if the surgery is done correctly.  Even if the surgery is done correctly, 25% of patients will still need revisional sinus surgery in the future.  Hence, selecting your surgeon is of paramount importance.

The development of the nasal endoscope has revolutionized the treatment of sinusitis.  The use of the endoscope has allowed us to preserve normal healthy sinuses by opening the natural pathways to the sinuses.  Once the improved drainage is achieved, the sinuses will re-establish normal functioning.  This is the theory behind minimally invasive sinus surgery technique.  FESS involves the placement of the endoscope (very thin fiber-optic tube), into the nostril for direct visualization of the sinus openings.  Using state-of-the-art instruments, diseased tissues and polyps are removed while the healthy mucosa is preserved.  The procedure is performed entirely through the nostrils without external incisions or cuts.  Our surgeries are all performed on an outpatient basis.  Postoperatively, our patients have a brief recovery period.

Image guidance is a near-three-dimensional mapping system utilizing stealth technology.  It combines computed tomography (CT) scans and real-time information about the exact position of the surgical instruments.  Image Guidance allows our surgeons to navigate through the complex sinuses and better target the obstructing tissues.   The surgeons at Alphasurg use the CT guidance along with endoscopes to provide targeted sinus surgery is the safest manner possible.

Our surgeons utilize the stealth technology to guide them through the approach to the frontal sinuses.  Given that the sinuses are in close proximity to the brain, orbit, and major arteries, this technology adds to the safety of the procedure.  Frontal sinus surgery can lead to complications.  Therefore, you must trust your surgery to only our experienced surgeons.  In addition, our surgeons are skilled at performing revision sinus surgeries. Laser is often a gimmick, but appropriate for some specific cases.  We are experts in CO2 laser, KTP, and others.

Balloon Sinuplasty™ technology has further revolutionized sinus surgery. Our surgeons are only one of a few who are trained in this latest technique. The theory behind this method is that the small balloon will enlarge the opening to the sinuses in a less disruptive manner. As a result, more normal anatomy is preserved allowing for faster recovery. Only certain patients are candidates for this device. Our surgeons will determine this after a complete exam.

The BEST Procedure (Balloon-assisted Endoscopic Sinussurgery with Targeting)
One of the basic mantras for sinus surgeons, as well as doctors, is to do no harm. Sinuses should not be operated on willy-nilly, but in a careful, thought out fashion. The use of minimally-invasive technology and atraumatic techniques is crucial to superior outcomes in sinus surgery. Typically, only the sinuses with disease should be operated on. Although there may be exceptions to this, most patients benefit from a targeted approach to treating only the involved sinuses. With the advent of advanced sinus imaging systems, this type of targeted sinus surgery is available at the Nasal and Sinus Institute. Using stereotatic imaging, we can zero in on those sinuses that need surgery. Also, when appropriate, we can use balloon technology to open sinus without the need for cutting. Seen the visuals below and call the Nasal and Sinus Institute to find out more.

Balloon Sinuplasty™ devices provide an endoscopic, catheter-based system for patients suffering from sinusitis. Recently published data in the leading ENT journal shows that the technology is safe and effective: study participants experienced no adverse events and received significant relief from their symptoms.

Balloon Sinuplasty™ technology is used by qualified Ear, Nose, and Throat (ENT) physicians and involves the use of tiny balloons to open blocked sinuses similar to how angioplasty uses balloons to open blocked coronary arteries.

The diagram below shows an inflamed left frontal sinus.

In order to improve symptoms of chronic sinusitis, an ENT physician will use Balloon Sinuplasty™ devices to open the blockage that is preventing sinus drainage.

The following picture summarizes the steps associated with using the Balloon SinuplastyT technology:

We had mastered the combination of Balloon Sinuplasty with stereotatic localization of sinus disease. Our BEST procedure is the least invasive, least traumatic, and most target sinus surgery available anywhere in the world!

Endoscopic Skull Base Surgery
Using similar approach to the sinuses, our surgeons are well-versed in using endoscopes for skull base surgeries which often present as an anatomical challenge with traditional approaches. Either it be correcting CSF (cerebrospinal fluid) leak secondary to skull base defects, removing benign/malignant tumors including clival tumors, this newest approach allows our surgeon to avoid external incisions or cuts. Also, pituitary tumors may also be removed endoscopically. Our approaches to the skull base are all performed internal to the nasal cavity. In doing so, we can usually avoid nerve deficit from older methods and can even avoid craniotomies (skull openings). Our surgeons are at the cutting edge of treating naso-sinus tumors as well as skull base tumors. When needed, we work with free flap surgeons for reconstruction, or neurosurgeons for more extensive tumors. We also work with interventional radiologists for certain complex tumor to pre-operatively reduce the blood supply to tumors making the surgical excision easier.

POSTOPERATIVE CARE

Even with expertly performed surgery, the surgery will be less likely to succeed if proper and careful follow-up after surgery is not done.  At our institute, we endeavor to follow our post-operative patients closely.  Proper treatment includes comprehensive care both medical and instrumental.  Often the healing phase is augmented with steroidal nasal sprays (which have minimal systemic absorption making them safe for use in most cases), leukotriene inhibitors, non-steroidal nasal sprays, allergy immunotherapy, nasal sinus lavage, and more.  The latter is key.  We will show the patient the best way to wash the nose after surgery to best help in the healing process.  For our out of town patients, we would be happy to coordinate follow-up within your local community.

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David M. Alessi, MD, FACS  

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