Troubles with the nose or sinuses are very common reasons for people to seek medical treatment. There is a wide range of problems that can affect these areas, ranging from allergies to cancers, but in general, there are several common symptoms that arise no matter what the underlying cause. They can include one or more of the following: trouble breathing through the nose (or nasal congestion), facial pain and pressure, headache, post-nasal drip or runny nose, sneezing, chronic coughing, and trouble smelling or tasting. These types of symptoms can be the result of true sinus infection, but can also simply result from nasal allergies, eye strain, migraine headaches, stress, or viral colds, or flu. Ultimately, Ears, Nose, and Throat (ENT) doctors are the experts in sorting out what the underlying cause of these problems may be, and whether or not nasal or sinus surgery is needed. ENT doctors also perform surgeries aimed at improving the overall health and function of the nose and sinuses. This article will focus on the structure and function of the sinuses, when sinus surgery may be required, and what patients can usually expect if indeed they require such measures.
Where Are the Sinuses? What Do They Do and How Do They “Go Bad”?
Sinuses are normally air-filled cavities within the skull that are lined with the same tissues that line the nose. There are two important elements within this tissue: cells that produce mucus, and hair cells that move mucus across the surface of the tissue so we can swallow or spit out these secretions. In the nose, mucus fluid helps trap debris, bacteria, or viruses that we inhale from the outside world. Mucus in the nose also helps to aid in the detection of odor molecules in foods that we enjoy, chemicals we want to avoid, or smoke that could warn us of fire. Since the sinuses are not typically thought to help fend off bacteria or viruses, and they are not for the most part exposed to the air that we breathe, it is unclear what role they play in this regard. At the least, they serve to lighten the weight of our heads and absorb a good amount of force during face-first collisions and thus help to protect deeper structures like the brain.
There are four major pairs of sinuses surrounding the nasal cavities. They are 1) the frontal sinuses in the forehead area, 2) the maxillary sinuses behind our cheeks, 3) the ethmoid (pronounce ethmoyd) sinuses between our eyes and 4) the sphenoid (pronounced sfenoyd) sinuses behind our nose and eyes, beneath the front portion of the brain.
The natural draining pathways of the sinuses are relatively small openings that are hidden within narrow corridors. While this may be an advantage in that foreign particles or insects that we inhale don’t end up getting inside our sinuses, it also means that it doesn’t take much swelling in the nose before these passageways are blocked. A blockage can mean that the mucus fluids that are normally swept up and out of the sinuses by the hair cells become trapped within the sinuses and become infected. Conditions that cause swelling in the nose such as allergies or colds and flues can therefore impair the sinus drainage and lead to trapped secretions in the sinuses. If trapped long enough, bacterial infection can lead to “sinusitis” or sinus infection. Even after the initial cold or allergy attack has subsided, infected secretions can spark enough inflammation as to keep the sinuses from draining, thereby setting up a cycle of continued sinus blockage and inflammation.
Diagnosing Nasal or Sinus Disorders and Sinus Infection
Determining the underlying causes of sinus complaints depends on a careful history and physical examination. Historical pieces such as the timing of the onset of symptoms, relieving factors, coincident upper respiratory illnesses (URI) such as a cold, trauma or surgery in the nose or sinuses, and allergy triggers all help to influence an ENT doctor’s suspicion that sinus infection is truly a concern. Examining the nose and sinuses typically involves looking up in the nose with a small camera after numbing the area with a nasal spray. In this way, ENT doctors can evaluate for the presence of pus indicating active infection, inflammatory masses known as nasal polyps, or overt signs of anatomic blockage of sinus drainages such as scar tissue, other types of masses, or tumors, or fungal infection. Depending on these findings, your doctor may recommend a sinus computed tomography (CT) scan to further evaluate the insides of the sinus cavities-as these areas are not generally visible during the camera examination. There may be some instances wherein your doctor may want a sinus CT scan right away, but usually, the best time to get one is after a good course of medicines to optimize the health and natural draining abilities of the sinuses. These medicines usually include strong antibiotics, anti-swelling medicines such as steroids, and sinus saline rinses. A sinus CT scan after 2-3 weeks of a regimen like this may show the sinuses to be clear, making the need for surgery less likely. However, if the CT scan shows trapped secretions within the sinuses even after these ‘optimal’ conditions, surgery to help open up the drainage pathways and wash out the sinuses may be indicated.
Sinus Surgery: What Does That Mean?
Sinus surgery has evolved over the past three decades as our understanding of how healthy sinuses function has grown. Again, even though the natural draining pathways of the sinuses are very small, most people will never need sinus surgery. When sinus surgery was first developed, doctors tried to optimize their abilities to drain by creating extra pathways from the sinuses into the nose with the idea that if one path is good, two or three paths are even better! What’s more, it was routine to strip the sinuses of that mucus-producing tissue in an effort to prevent trapped secretions from building up again. It turns out that these patients often continued to be troubled by recurrent sinus infections or crusting and bleeding in the nose. This is because those hair cells that line the sinuses all move together in a specific, coordinated fashion to move secretions only toward the area of the natural openings, no matter how many other exit paths there are in the sinus.
Strategies in sinus surgery have therefore turned to optimize the natural openings while preserving the tissue lining whenever possible. Currently, this is the accepted method of sinus surgery and involves using cameras in the nose to expand the natural drainage paths, wash out secretion, and removing infected material only. In some instances, ENT surgeons can pass a small balloon into the sinus openings and inflate the balloon to expand the pathways—much like a heart doctor can open a blockage in a heart vessel. The vast majority of sinus surgery is done on an outpatient basis and involves 2-3 visits to the doctor so he or she can check and clean the areas involved.
In summary, not all nasal complaints can be attributed to sinus disease, and not all sinus diseases will require sinus surgery. It is important to consider other causes of nasal congestion or headache such as nasal allergies, stress, visual changes, and many others. What’s more, even in the event of a true sinus infection, the appropriate timing of a CT scan may help to avoid unnecessary sinus surgery. Nevertheless, sinus surgery itself has never been safer or less invasive than it is today, and is usually an outpatient procedure.
Your best bet is to seek consultation with a qualified ENT doctor who can assess and treat nasal and sinus problems, interpret sinus findings on CT scan in the context of when the scan was obtained (i.e. during symptoms but before treatment, or after optimal medical treatment), and offer safe and effective surgical intervention if that is required to break the cycle of repeated inflammation and impaired sinus drainage.