Richmond’s Sinus and Allergy Specialists

ent1When antibiotics and nasal steroids fail to control sinus symptoms, surgery may offer prompt and lasting relief. With current technology, the majority of patients can be treated with a simple balloon dilation in the office, much like an angioplasty.  If wider openings are required, endoscopic sinus surgery can be performed at the attached Medarva Stony Point Surgery Center .

If you answer “yes” to one or more of the following questions, you may wish to see an ENT specialist (otolaryngologist) for a thorough evaluation of your sinuses and to determine if surgery might be right for you:

  • Do you have frequent facial pain or pressure?
  • Do you have chronic nasal discharge?
  • Do you have difficulty breathing through your nose?
  • Is your sense of smell or taste impaired?
  • Do you get three or more sinus infections per year?
  • Do you require more than one antibiotic to treat a sinus infection?
  • Have had polyps in your nose or sinuses?
  • Have you had swelling or fluid in your sinuses on CT scan?

What is Functional Endoscopic Sinus Surgery?

If your sinuses become frequently or permanently blocked, a surgeon can enlarge the drainage pathways by cutting out the crowded or diseased tissue surgically. Modern sinus surgery is performed using endoscopes: small telescopes that are designed to fit easily inside the nose.  These provide the surgeon with a magnified, “endoscopic” view of your nasal and sinus cavity. The term “functional” refers to the concept of removing only enough tissue to create effective drainage, while preserving as much of the normal anatomy and mucous membrane as practical. The surgical plan will be based on your symptoms, your office endoscopic examination, and your CT scan.

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With chronic sinusitis, mucous becomes trapped in the compartments of the sinuses (left side). Functional endoscopic sinus sugery removes the small bony partitions, creating larger drainage pathways (right side)

Where exactly are my sinuses?

ent3There are conceptually 5 major sinus areas on each side.  The frontal and maxillary sinuses are large open cavities above and below each eye, respectively.  Each opens into the nose through a narrow passage.  Blockage of the frontal sinus often causes headaches in the forehead, while blockage of the maxillary sinuses causes cheek, face or tooth pain.  The sphenoid sinuses are large cavities behind the eyes – almost between the ears.  The optic nerve (which supplies vision from the retina), the internal carotid artery (which supplies blood to the brain) and the pituitary gland (which controls growth, the thyroid and the reproductive system) are all situated within or along the sphenoid sinus.  Infections in the sphenoid can therefore become quite dangerous.  Pain in this sinus can be described as coming from anywhere in the head, including the back of the head (occiput). The ethmoid sinus is more like a honeycomb than a cavity, and contains multiple small air pockets separated by paper thin bone. The ethmoids are directly between the eye sockets and extend up to the base of the frontal lobe of the brain. Surgeons divide the ethmoid cavity into an anterior portion, which drains in front of and beneath the middle turbinate, and a posterior portion, which drains behind the middle turbinate.

What happens at surgery?

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Limited endoscopic surgery to open the maxillary sinuses

The original concept of functional endoscopic sinus surgery was to remove the honeycomb-like ethmoid sinuses so that the larger frontal, sphenoid and maxillary sinuses can drain directly into the nose. Using the endoscope for a close-up view, the surgeon removes bone and soft tissue to enlarge the natural opening of each sinus, and removes the ethmoid sinus in between.  The ethmoid sinus has been described as the keystone area, with the thought that infection and swelling in the ethmoid backs up into the larger sinuses. Over time, surgeons found that they could remove less and less tissue as long as the larger sinuses were drained.  With selected patients, such minimally invasive sinus surgery could even be performed in the office under local anesthesia.[1] The introduction of Balloon Sinuplasty has created a new way of thinking about endoscopic sinus surgery – a recent study conducted partly at Richmond ENT demonstrated that balloon dilation of the maxillary sinus alone can improve disease in the ethmoid sinus as well.[2]

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Complete endoscopic dissection of all the sinuses

Will I have pain and nasal packing?

Sinus surgery causes surprisingly little pain in most patients. The bones dividing the ethmoid sinuses are as thin as a robin’s eggshell.  In a recent publication, our patients used prescription pain medication for less than 5 days, and resumed normal activity in 4.5 days, on average.[3]  Typically we prescribe an oral narcotic pain reliever for a few days, depending on the extent of the surgery.    Prescription pain medications are not usually needed following Balloon Sinuplasty alone.

Nasal packing is dependent upon the severity of bleeding in surgery.  With limited surgery, we try to avoid nasal packing altogether. Patients with nasal polyps almost always require some packing, but usually the soft foam sponge is smaller than the polyps removed.  Despite our best efforts, you should be prepared for the possibility that breathing through the nose may be worse for the first week after surgery.

What do I do after surgery?

After any general anesthetic, you should go home and rest for the day.  Do not make any important decisions or drive a car for at least 24 hours after taking prescription pain relievers.  Keep your head elevated to reduce swelling.  Warm, moist air will be soothing. Use cold compresses only if you have had a rhinoplasty.

After sinus surgery, crusts will usually accumulate in the sinus. These can cause residual infections and scarring that leads to further sinus trouble. Irrigating with sterile salt water (saline) will help you to keep your nose clean.  You should not blow your nose for at least two weeks, as forceful blowing or sneezing can force air or infected mucous into the eye socket or brain cavity. Remember to continue all allergy and sinus medications that you were taking before surgery, including nasal steroid sprays. The surgery is not a cure for allergy.

Your surgeon will want to examine your nose in the office within a week after endoscopic sinus surgery, and may spend some time and effort cleaning your nose. Several such visits may be required, depending on the health of your nose at follow-up.  Unlike most types of surgery, the professional fees for sinus surgery do not include postoperative endoscopy and cleaning.  Depending on your insurance, you may need referrals for these visits and you should expect that they will be billed separately from the main surgery.

Remember the following after surgery:

  • Do not blow your nose
  • Continue allergy medications
  • Irrigate with salt water
  • Keep your appointments

Click here for detailed postoperative instructions

What are the risks of sinus surgery?

Major complications from sinus surgery are exceedingly rare.  However, sinus surgery involves the removal of bone and tissue very close to brain and in between the eyes.  Injuries to the brain, spinal fluid leakage, meningitis, blindness, double vision and loss of smell have all been described after endoscopic sinus surgery. General anesthesia alone can cause serious complications, including stroke, heart attack, tooth injury, voice injury and death. Again, these risks are serious but rare – as are the risks of driving an automobile. More common, but less serious complications include nasal obstruction, bleeding, soreness, persistent infection, and need for reoperation. Select a surgeon who is certified by the American Board of Otolaryngology – Head and Neck Surgery and who has good training and experience with endoscopic sinus surgery.


[1] Armstrong, M:  Office Endoscopic Sinus Surgery.  Presented at the American Rhinologic Society, Palm Desert, CA, April 26, 1999.  Armstrong, M. Office-based Procedures in Rhinosinusitis.  Otolaryngol Clin N Am 38:1327-1338, 2005.

[2] Levine SB, Truitt T, Schwartz M, Atkins J: In-Office Stand-Alone Balloon Dilation of Maxillary Sinus Ostia and Ethmoid infundibula in Adults with Chronic or Recurrent Acute Rhinosinusitis: A Prospective, Multi-institutional Study with 1-Year Follow-Up. Ann Otol Rhinol Laryngol 122(11):665-671, 2013.

[3] Cutler J, Bikhazi N, Light J, et al. Standalone balloon dilation versus sinus surgery for chronic rhinosinusitis: A prospective, multicenter, randomized, controlled trial. Am J Rhinol Allergy 27:416-422, 2013.