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Nasal Septal

If you have had surgery and you are still having trouble

This is a pretty common situation. Unfortunately, many patients assume that they must live with their sinus problem because surgery didn't work. In most cases, that just isn't true.

There are many reasons why sinus and nasal surgery might not have given good relief. Once the reason is identified there is almost always a plan of action that can lead to eventual relief or improvement of symptoms.

Reasons why surgery might not work
and what can be done about it.

General -

Many people have had some type of nasal procedure and didn't get the benefits that they had hoped for. There are some very specific reasons for this in most cases.

Some problems can't be easily fixed, but some can. In my practice, only a fraction of those who continue with post operative problems require additional procedures. My workup for such patients includes (the workup varies with the situation):
  • Performing cultures to be sure that there aren't resistant bacteria involved
  • Extended duration of carefully selected antibiotic therapy
  • Antifungal irrigations
  • Judicious use of oral steroids for polyps or allergic fungal sinusitis
  • Endoscopic exams to evaluate the post operative condition of the sinuses
  • Repeat CT scans to determine the location and extent of the persisting problem
Here is a list of the common reasons for the failures of sinus and nasal surgery and what I would usually do to help such patients.

Problem - older less effective technique used

Prior to about 1991, there was basically no endoscopic sinus surgery performed. Between about 1991 and 1994 the field was rapidly developing and very few surgeons had good experience using the tools and techniques that we now take for granted. The only sinuses that were commonly operated on were the maxillary sinuses. Problems in the ethmoids, frontals, and sphenoids were very difficult to treat and to diagnose.

The common non-endoscopic operation was to perform a septoplasty if needed, place naso-antral windows, and possible remove a portion of the inferior turbinate (sometimes too much). If such patients had disease in the ethmoids, frontals, or sphenoids, they would usually only get a partial improvement. This is a very common scenario. Before endoscopic techniques it was dangerous to get into these sinuses and it required incisions on the face that left scars. Its understandable that these commonly infected and involved areas were left alone.

Patients who had procedures done before endoscopic surgery will often continue with chronic ethmoid, frontal, or sphenoid sinusitis. Also, the "windows" may cause a phenomenon that allows mucous to accumulate near the still blocked natural opening, it collects, then falls down and out of the window all at once.

Solution - I will usually find out the extent, nature, and location of residual problems with a CT scan. Often this leads to prolonged courses of antibiotics, steroid sprays, and perhaps allergy medicines. Sometimes, if everything is done just right, longstanding problems can be cleared with medicines.

When medicine will not clear the chronic problem, modern endoscopic revision procedures can be considered. Revision procedures are usually minor in that they are outpatient, often do not require packing, and would usually not include a septoplasty.

Problem - the wrong operation was performed

This statement isn't quite what it seems, let me explain. A common scenario of failure that I see is in the patient who presented with a complaint of congestion and trouble breathing, perhaps even sinus pain. The doctor looked in the patients nose and discovered a significant nasal septal deviation. He thinks to himself, "that crooked septum is probably causing the patient's symptoms and needs to be corrected". He is correct. The missed opportunity was that other problems that can exist along with a deviated septum were not explored. Chronic sinusitis is very common, and probably more common in people with severe septal deviations.

After repairing the septal deviation the patient may breath a bit better, but the problems aren't entirely corrected. It turns out that such patients often also have a significant chronic sinusitis that was part of the problem but perhaps didn't have characteristic symptoms. If the doctor had done a CT scan before surgery, then these unexpected issues may have been revealed. In fact, in this scenario, the chronic sinusitis may have been clearable with proper medicines and surgery avoided all together. This is the worst case scenario, having a procedure that isn't helpful for a problem that might clear with medicine. It is an easy trap for modern physicians who are trying to be thrifty with our limited healthcare dollars and when CT scans can be expensive, and would most often not reveal unexpected problems.

Solution - When a patient has a septoplasty and later proves to have chronic sinusitis, the workup starts over. Now the doctor has the benefit of a more open nasal airway. Certainly many patients can have their chronic sinusitis cleared with appropriate medicines. In some cases, when medicine isn't working, modern endoscopic procedures can finish the process giving the patient long overdue relief. The septoplasty is usually more traumatic than the endoscopic sinus procedures. Patients do not want to relive the experience that they had before, and fortunately they usually do not have to.

Problem - fooled by the conservative approach

This happens to all sinus doctors from time to time. A common scenario is that a patient has the story of chronic sinusitis, a long regimen of antibiotics is given, a CT scan is obtained at the end and it shows certain sinuses that have become difficult to clear. A minor procedure is performed to open those particularly difficult sinuses, and other sinuses are left undisturbed, as they should be. After surgery things are better but the patient develops infections that once again are hard to clear. Eventually another CT scan is obtained, and it shows that some of the sinuses that were not operated on are the ones contributing to the difficult infections.

This scenario is not that uncommon. The initial premise that modern sinus surgery tries to follow is that you should not disturb structures that are not causing a problem. This seems reasonable enough, but to really know if removing a structure will help sinus problems is not always that easy. In the patient in the scenario above, it was assumed that the CT revealed a chronic source of infection and that it was at the root of recurrences and flare-ups. As the story progressed after surgery, it might reveal that they had multiple areas that caused problems, but that some were "cooled down" at the time of the CT scan.

Despite this shortcoming in the logic of our modern techniques, there is little that can be done to avoid this pitfall. I will typically do a good examination of the areas that I am not planning on operating just to be sure that they look good through the scope as well as on the CT scan. The other way to help get information about such areas would be to do a CT scan at times when the patient is more symptomatic. The problem here is that one would probably operate on areas that could be cleared with medicine.

Solution - The first things that is done is to review all of the medical therapy that has been used. The sinuses that are causing trouble now were clear on one CT scan, so we know that they can clear with medicine. Revisiting the medical regimens that could keep these areas in check is needed.

When a patient needs a second operation because of this sequence of events, I think it is wise to change the philosophy. The goal of a first (hopefully only) sinus procedure is to do the least work that will likely relieve the problem; this serves most patients very well. The goal of the second operation is to be pretty sure that there won't be a third operation. With this philosophy, I usually open any sinus that is a possible suspect where it is safe and simple to do so. This varies with patient's history and anatomy.

Problem - allergic fungal sinusitis and polyps

Some patients with chronic sinusitis have a problem called Allergic Fungal Sinusitis, (AFS). This is one group of patients that is often not "cured" with sinus surgery. This problem amounts to a reaction that some people have to mold spores that are in the air. It is not actually an allergic (IgE) reaction. People with this problem typically have nasal polyps and have a thick material filling one or more sinuses. Some controversial theories suggest that many patients who don't have polyps or obvious fungal material may have the same reaction but to a lesser degree.

People with allergic fungal sinusitis are more prone to re-grow polyps and can have swelling even if all of the problem sinuses are open and well treated. In these cases, surgery is very helpful and is one of the only hopes of having less trouble, but in some patients the process continues despite surgery and medicines.

Solution - For some patients there is no easy solution to this problem. Surgery almost always makes symptoms less and makes AFS flare ups easier to treat and diagnose. Oral steroids like Prednisone are dramatically helpful, but they have side effects that make them unsuitable for frequent or prolonged use.

Rinsing with anti-fungal medicines has been shown to help reduce recurrences. These rinses are not likely to be helpful unless the sinuses are surgically opened.

Careful follow up in patients with AFS, use of steroids where appropriate, and the use of topical anti-fungal agents can help reduce recurrences in patients with AFS.

Some patients with AFS may end up needing occasional removal of polyps or sometimes re-operation with more extensive procedures to control the disease. The statistics vary, but about 25% of patients with allergic fungal sinusitis will benefit from a second operation.

Problem - other types of polyps

Some polyps are from causes unclear. When that is the case, sometimes they can be removed and never come back, other times, no matter what is done the polyps return. In some patients with polyps, it may be necessary to go back and clean out any re growth to provide drainage and nasal airway. When this becomes necessary, the return trips to the OR can often be spread out by many years and the return trips are usually minor procedures. The goal is to use the two most helpful therapies: steroids and surgery, in a way that causes the least expense and danger to the patient, but still controls the problems.

Problem - the surgical sites didn't heal as expected

There are times when the perfect operation is performed on the perfect patient, and things don't heal up as expected. There are certain problems that can happen in the post-operative period that are well known. Some people might refer to this as "scar tissue" forming. The problem is actually that mucous membranes healed over places that we wanted to stay open or heal two adjacent structures together.

Poor healing is most likely in patients with active inflammation at the time of surgery. Some problems are more inflammatory than others and this is fairly easy to evaluate at the time of surgery. Poor healing can also happen more easily in patients with very small nasal anatomy.

Solution - When areas heal poorly after surgery and continue to cause problems, it is usually necessary to try and correct this surgically. Often minor tune-ups can be performed in the office during an office visit. This is especially true if the maxillary sinus opening has healed closed or if the middle turbinate has healed laterally. When a return trip to the operating room is needed, the procedure is usually minimal.

Problem - infection persists despite sinuses being opened

In my opinion, this can be the worst situation. Out of the many patients I deal with each year, about 2 or 3 will have this problem. It usually happens in people who have had a long standing bacterial infection in the maxillary sinuses or those with some type of immune problem like diabetes.

In such patients, after surgery, the sinuses may heal as expected, but puddles of apparent infection remain pooled in the bottom of the maxillary sinuses. Bacterial cultures are taken but for some reason, they frequently do not reveal the bacteria that is at the root of the problem. Perhaps bacterial are not really at the root of the problem, but it appears that they are. So multiple antibiotics are given, based on educated guessing, but the puddles persist. The most common symptom is post nasal drip and cough.

Solution - This is a difficult problem, and usually a resolution can be achieved. In my practice, the next steps involve:
  • Repeating cultures, because sometimes an unexpected bacteria is identified and treated with special antibiotics
  • Frequent clinic returns and instilling strong antibiotics directly into the sinus and cleaning out of the sinus. While it is never done, I think that if such patients were put to sleep every day for a couple of weeks, and their sinus was rinsed out aggressively and antibiotics place in the sinus, such patients would clear up. This is not practical, but in office visits 2 or 3 times a week for rinsing and antibiotics is sometimes possible to arrange
  • Using antibiotic rinses at home
  • Prolonged intravenous antibiotics can be useful in some cases
  • Considering placing a "window" at the bottom of the sinus. This lets the material drain by gravity some and allows antibiotic and or saline rinses to get into the sinus more completely
  • Eventually one can "saucerize" the sinus, and this almost always improves the volume of infection and permits the infection to be better controlled. The negative is that it changes the natural anatomy dramatically and most patients will get relief without taking this step

Everything about
Sinus Surgery

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What is balloon sinus

Does sinus surgery
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I have had sinus surgery
  and I am still having
  What should I do?

What is the recovery
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Post-operative visits:
  They are important.

What is a septoplasty?

What is a turbinate

Is packing still necessary?

What are windows?

How painful is modern
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What complications
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