Sinus surgery is a procedure that strives to open the sinus passages for the purpose of reducing the chance of continued infections. Nose sinus surgery is done endoscopically or with balloon sinuplasty for a minimally-invasive approach. For severe sinusitis problems, traditional nasal sinus surgery may be needed with internal incisions to enlarge the airways. Dr. Gary Linkov is a board-certified plastic surgeon at City Facial Plastics in New York who performs sinus surgery to open the nasal and sinus passages for patients with chronic sinusitis.
What Is Chronic Rhinosinusitis?
Chronic rhinosinusitis, or chronic sinusitis, is highly prevalent in the United States and around the world, affecting at least 15% of the adult population. Chronic rhinosinusitis (CRS) is defined by symptoms that last greater than 12 weeks.
Symptoms can include:
- Sinus tenderness on palpation
- Mucosal erythema
- Purulent nasal secretions
- Increased pharyngeal secretions
- Periorbital edema
CRS is first treated with medical therapies including oral medications and topical nasal sprays. Allergy testing and immunotherapy may also be appropriate. If symptoms progress despite maximal medical therapy then chronic sinusitis surgery should be considered. The presence of nasal polyps may be an indication to consider nose sinus surgery earlier in the treatment algorithm.
What Is Sinus Surgery?
Sinus surgery was first described in the 1600s and involved making a hole into the cheek sinus from the outside of the nose, under the upper lip. Nasal sinus surgery techniques have since advanced and now offer a safer and less traumatic approach to treating the sinuses.
The pendulum has swung towards less aggressive approaches that preserve the sinonasal mucosa (inner lining of the nose) and maximize function after surgery, hence the term “functional sinus surgery.” We also have a better understanding of how to combine surgical approaches with medical therapies to treat CRS and other sinonasal conditions.
Combining Sinus and Nose Surgery
Dr. Gary Linkov is an experienced facial plastic surgeon who performs both functional and cosmetic nose surgeries. When severe sinus issues are present and a patient also wants a cosmetic change to their nose, both procedures can be performed at the same time. Combining both procedures into one surgery can reduce the trauma to the nose and patient.
Who Is a Good Candidate for Sinus Surgery in Manhattan, NYC?
Nose sinus surgery has a role in benign and life-threatening sinonasal conditions, including:
- Chronic rhinosinusitis with or without nasal polyps: “blocked sinus” (requires blocked sinus surgery)
- Recurrent acute rhinosinusitis
- Complications of rhinosinusitis
- Sinonasal polyps
- Noninvasive fungal ball and eosinophilic fungal rhinosinusitis
- Invasive fungal rhinosinusitis
- Intractable epistaxis
- Cerebrospinal fluid rhinorrhea and anterior meningoencephaloceles
- Foreign body removal
- Choanal atresia repair
- Headaches and facial pain
- Silent sinus syndrome
- Sinonasal tumors
- Expanded transnasal approaches to the skull base and orbit
What Is the Relevant Anatomy for Sinus Surgery?
- First sinus to appear during development
- The largest of the sinuses
- Sometimes referred to as the “cheek” sinus as it is located at the level of the cheek, above the lip, and to the side of the nose
- Located between the eyes
- Made of air cells that are numerous thin-walled cavities
- Separated into anterior and posterior groups
- Located behind the lower forehead
- Usually divided into two parts by a central septum
- Significant size and shape variation between people and may be absent in some
- Situated at the back of the nose, the most posterior sinus
- Close proximity to the optic nerve and carotid artery which are always at risk for injury when working in this sinus
Osteomeatal Complex (OMC)
- The final common pathway for drainage and ventilation of the ethmoid, maxillary, and frontal sinuses
- It comprises structures bound between the medial orbital wall and the middle turbinate
- Medical and surgical strategies are meant to eliminate OMC obstruction and restore sinonasal function
- Shelves on the lateral aspect of the inner nose that aid with nasal airflow, moisture, and filtration of outside air
- The inferior turbinate may sometimes be too big and reduce nasal airflow
- The middle turbinate is an important landmark in sinus surgery and is manipulated to access the ethmoid, frontal, and maxillary sinuses
- The superior turbinate can be used as a landmark during nose sinus surgery to help identify the sphenoid sinus
- Central partition between the two sides of the nose
- A deviated septum may present challenges to performing a thorough nasal sinus surgery and may need to be corrected during surgery
- Paper thin bone that separates the nose from the brain at the anterior skull base
- It may be thinned further by conditions such as CRS
- Careful attention must be paid to this structure during sinus surgery to avoid devastating complications of CSF leak and other problems
What Are the Types of Sinus Surgery?
There are four main types of sinus surgery NYC approaches, including:
Endoscopic sinus surgery
Endoscopic sinus surgery involves using advanced surgical telescopes during surgery to promote visualization. This is the most modern form of sinus surgery and has become the most commonly performed nose sinus surgery. No incisions are made on the outside of the face.
The surgeon holds the telescope with one hand and uses a surgical instrument in the other to gain entry to different sinuses and treat the underlying condition. This surgery is performed under general anesthesia for patient comfort and to minimize the chance of patient movement while the surgeon works throughout the inside of the nose.
Image-guided sinus surgery
Image guidance refers to using an additional technology to aid the surgeon during endoscopic sinus surgery. A CT or MRI of the sinuses is obtained prior to surgery and the data is loaded into a special system. During surgery, the surgeon can configure the system so that as he waves an instrument over a specific structure inside the nose, the corresponding area on the imaging software is revealed.
This heightened level of awareness helps the surgeon avoid injuring critical structures and keeps the surgeon on course during sinus surgery. While image-guidance is not always used for primary sinus surgery, it can be a useful asset for revision surgery or when the native anatomy is distorted by disease.
Caldwell-Luc sinus surgery
Caldwell-Luc sinus surgery is one of the original approaches described to reach the maxillary (cheek) sinus. The incision is made on the inside of the upper lip and the front of the cheek bone is identified. A window into the bone is made to gain access to the inside of the cheek sinus. While this approach may seem antiquated, there are still certain indications for this approach, despite how advanced our endoscopic techniques have become.
Balloon sinus surgery
Sinus balloon surgery was introduced in the mid-2000s and involves using an expandable balloon attached to a device for deployment. The balloon in a deflated state is passed inside the nose towards the desired sinus opening and the balloon is expanded to partly expand that opening. Balloon sinus surgery (sinuplasty) has gained popularity since it can be performed without general anesthesia, in the office setting. It can also be combined with endoscopic sinus surgery for difficult to reach areas, such as the frontal sinus.
How Is Sinus Surgery Done?
The major steps of an endoscopic sinus surgery include:
- Anesthesia – Once the patient is under general anesthesia, 1% lidocaine with epinephrine injected and topical vasoconstriction is used to provide local anesthesia and mainly to shrink the blood vessels to reduce bleeding during the procedure.
- Middle turbinate medialization – The middle turbinate is gently medialized in order to expose the osteomeatal complex.
- Uncinectomy – Instruments are used to remove the majority of the uncinate bone.
- Maxillary antrostomy – A 30 or 45-degree endoscope is used to identify the maxillary sinus ostium, the floor of the orbit, and the medial orbital wall (lamina papyracea). The maxillary ostium is expanded as needed to prevent stenosis in the recovery period.
- Removal of ethmoid bulla – The ethmoid bulla is entered to begin work inside of the anterior ethmoid sinus.
- Identify basal lamella – The basal lamella of the middle turbinate is identified and penetrated to enter into the posterior ethmoid sinus.
- Ethmoidectomy – Ethmoidectomy is performed to open-air cells and improve drainage pathways. Polyps are removed at this time if present. Extreme caution is taken not to injure the eye or the brain.
- Sphenoid face identification – The sphenoid sinus is identified using several landmarks and entered if needed.
- Frontal recess identification – The frontal recess is identified and frontal sinusotomy may be performed if indicated.
- Concluding the procedure – Bleeding is controlled with cautery, topical vasoconstriction, and hemostatic substances as needed. Packing is avoided if possible.
How to Prepare for Sinus Surgery?
In preparation for your nasal sinus surgery at City Facial Plastics in Midtown, Manhattan, the following information is helpful:
- Avoid certain medications and supplements that may thin the blood
- Stop smoking at least 2 weeks before surgery, as tobacco products can decrease blood flow to the skin and compromise the healing of the surgical site
- Stop all nasal sprays 2 weeks before surgery, with the exception of saline which you can continue
- If prescribed by your doctor, take the preoperative antibiotics and oral steroids to reduce the risk of bleeding and infection
What to Expect on the Day of the Procedure?
Do not eat or drink 6 hours before your scheduled surgery. Sinus surgery is performed under general anesthesia with an anesthesiologist present. There will be no pain during the surgery and you will have no recollection of the procedure. Your time at the ambulatory surgery center will be about 6 hours, with 3-4 hours of actual surgical time.
What Is the Recovery From Sinus Surgery?
The following information is useful to keep in mind for the sinus surgery recovery, including:
- The nose will be stuffy for the first few days to weeks.
- There may be light bleeding from the nose for the first 48 hours, rarely is it more severe.
- Nasal saline spray is initiated about 48 hours after surgery and used several times a day to prevent crusting and help release the dried blood.
- It is important to avoid strenuous activity such as exercise or heavy lifting for at least several weeks postoperatively.
- It is also important to avoid nose blowing for several weeks.
- Take any additional medications prescribed to you by your doctor.
What Are the Risks and Complications of Sinus Surgery?
Nose sinus surgery risks ad complications include:
- Persistent nasal congestion
- Decreased sense of smell
- Facial numbness
- Eye injury
- Brain injury (CSF leak)
- Anesthetic complications
Can Sinus Surgery Cause Vertigo?
Vertigo, such as that caused by benign paroxysmal positional vertigo (BPPV) has been very rarely associated with nasal surgery, specifically septoplasty. There are only a few case studies. The primary mechanism is believed to be vibration trauma along the bone that is carried to the balance control central of the inner ears (semicircular canals).
Will Sinus Surgery Help Sleep Apnea?
Pooled results have shown that isolated nasal and sinus surgery for patients with obstructive sleep apnea could improve subjective sleep parameters and reduce daytime sleepiness, but has no significant improvements on objective parameters. Nose sinus surgery is not a first-line surgical treatment for sleep apnea.
What Are the Contraindications for Sinus Surgery?
There are patients who should not have sinus surgeries, these include patients with the following:
- Health conditions that would make surgery dangerous
- Conditions of the skull base or orbit that prevent a safe approach to the sinuses
- Nasal polyps are a contraindication to balloon sinuplasty alone
What Are the Alternatives to Sinus Surgery?
As described above, alternatives to nasal sinus surgery are:
- Observation (no surgery)
- Medical therapy
Are Patients Satisfied After Sinus Surgery?
Studies have collectively shown an 80% to 98% improvement in nasal symptoms after sinus infection surgery. Patients often report better nasal breathing, fewer sinus infections, and less nasal drainage after surgery. Patients who have CRS with polyps need to be aware that the polyps most often return after a number of years if no medical therapy is initiated after surgery.
Who Does Sinus Surgery?
Nasal sinus surgery is almost exclusively performed by otolaryngologists, such as Dr. Linkov. These are Ear, Nose, and Throat specialists with extensive training in all aspects of head and neck surgery. Internal nasal anatomy is complex and in close association with other vital structures that need to be protected during sinus surgery.
What Is the Cost of Sinus Surgery?
Most sinus surgery costs are covered by insurance. Keep in mind that certain surgeons are not in-network providers. Many insurance policies have out-of-network coverage which may apply. As long as the sinus surgery is performed in the proper ambulatory surgical center then the facility and anesthesia fees are covered by insurance as in-network.
Who Is the Best Sinus Surgery Doctor in NYC?
Dr. Gary Linkov is a board-certified otolaryngologist (head and neck surgeon / ENT) and facial plastic surgeon in Manhattan, NY. Dr. Linkov is a busy septoplasty and rhinoplasty surgeon with extensive experience treating all conditions of the nose.
He is the Chief of Otolaryngology and Facial Plastic Surgery for the Veterans Hospital in Brooklyn, NY, where he operates on complex nasal deformities and performs sinus surgery, serving our country’s veterans. Dr. Linkov’s private practice in Manhattan’s Upper East Side focuses on nasal procedures, including endoscopic sinus surgery.
If you have severe sinus problems and want to get relief, sinus surgery could be the right option for you. Dr. Linkov performs nose sinus surgery on its own or in combination with rhinoplasty at our practice in New York City. Contact City Facial Plastics, located in UES, Manhattan, to schedule your appointment with Dr. Linkov to discuss your nose surgery options to give you relief from chronic sinusitis.