The Seattle Sinus Surgery Center™
Patients’ Complete Guide to Endoscopic Sinus Surgery
Functional Endoscopic Sinus Surgery (FESS) is one of the most challenging operations for the Otolaryngologist (ear, nose and throat surgeon) to perform. It is also very rewarding for both the surgeon and the patient since it dramatically helps airflow dynamics through the nose a well as open sinuses. It allows a normal functionality of the sinus pathway, and drainage. Functional endoscopic sinus surgery is performed on patients with chronic sinusitis; to remove polyps, open up sinus passageway and to improve breathing. It also helps to rid facial headaches, pain and pressure that occur typically from chronic sinusitis. It is a very common procedure done in the United States by Otolaryngologists since it is common to have chronic sinusitis and also noted to occur in families. Chronic sinusitis can be hereditary, which is related to allergies that cause sinus polyps to grow. Endoscopic sinus surgery is not done for any cosmetic reasons; Rhinoplasty is done for osmetic purposes in the nose. A Septoplasty is performed for a deviated nasal septum to improve the patients’ functional breathing on the inside of the nose and turbinate reduction surgery on the inferior turbinates is performed on the inside of the nose to improve breathing parameters as well. This is usually done as a submucucous resection and an outfracture o the inferior turbinates designed to improve airflow. There are four paired sinuses in the face; frontal, ethmoid, maxillary and sphenoid sinuses. Please see accompanying diagrams for an anatomical illustration. A Rhinoplasty is done for cosmetic purposes and can be performed aat the same time as endoscopic sinus surgery. Any cosmetic surgery is paid for by the patient and not billed to insurance, however, sinus surgery, Septoplasty and Turbinate surgery are billed to insurance out of medical necessity. A broken nose can also be repaired at the same time if needed. The nasal anatomy is one of the more complex of all surgical procedures done by an Otolaryngologist because of the three-dimensional structure of the nose, which includes bone, cartilage and skin. The sinus cavities are uniquely shaped for each individual face and this has to be taken into account during the endoscopic sinus surgery. All of the incisions for the endoscopic sinus surgery are placed up high inside the nose and there is no external incision. Nasal endoscopes (telescopes) are used to guide Dr. Portuese through the anatomical structures insie the nose. Limitations of functional endoscopic sinus surgery are very few, but when patients have massive nasal polyps there is a high likelihood they will require more than one operation in their lifetime to remove the polyps again. It is important that patients have realistic expectations regarding their endoscopic sinus surgery outcome; the goal of the surgery is to break the cycle of infections, to get rid of facial headaches, facial pain and pressure, post nasal drip and drainage, congestion and to improve airflow dynamics through the nose. In addition, improving the sense of smell is also very important.
NORMAL SINUS ANATOMY
SIDE VIEW OF NORMAL SINUSES
This creates nasal
and can cause headaches.
This is caused by bacterial
inflamation of sinus.
SINUS POLYPS FRONT VIEW
SINUS POLYPS SIDE VIEW
Polyps develop in sinuses from long term infections, allergies and sinusitis.
The earliest age at which endoscopic sinus surgery should be performed is usually late teens. On rare occasions, endoscopic sinus surgery can be performed on pediatric patients, but there are other underlying etiologies that need to be addressed in this patient population and this is typically done by a pediatric otolaryngologist. It is usually important that the facial growth plates and nasal cartilage growth plates have completely finished growing until any endoscopic sinus surgery, including Septoplasty, is performed. The nose stops growing at age 15 for girls and at about age 17 for boys. It is also important that the patient is in excellent health and doesn’t’ have other preexisting medical conditions, such as asthma. Asthma is a very common condition which coexists with patients who have extensive nasal polyposis. Patients need to make sure that their asthma is under control prior to undergoing a general anesthetic and it is also very important to follow all pre and post operative care instructions for seamless post operative course and recovery. Other chronic health problems, such as kidney disease, lung, heart, liver and diabetes may render a patient unsuitable for outpatient endoscopic sinus surgery. Uncontrolled high blood pressure may cause nosebleeds, uncontrolled diabetes may cause infections and smoking can cause delay in the healing process.
The Surgeon – Dr. Portuese
Dr. Portuese is Board Certified in Otolaryngology, head and neck surgery (ear, nose and throat surgery) and his expertise in the sinus area is extensive with over 25 years of experience – performing thousands of functional endoscopic sinus surgeries. Choosing the right surgeon to perform functional endoscopic sinus surgery is of utmost concern and it very important that the surgeon performing the functional endoscopic sinus surgery has performed thousands of them. Dr. Portuese’s surgery center is called The Seattle Sinus Surgery Center and is a Medicare Certified Ambulatory Surgery Center located at 1101 Madison Street, Suite 1280. This is adjacent to Swedish Medical Center. The certified surgical team consists of four Registered Nurses who have been working in outpatient surgery for over 30 combined years.
General anesthesia is preferred for endoscopic sinus surgery; it is very important that patients are asleep during this procedure as patients will not be able to tolerate twilight or IV Sedation anesthesia. It is also important that a controlled airway is present during the procedure so that blood does not go down the back of the throat. Board Certified physician anesthesiologists from Swedish Medical Center perform the anesthesia in our Medicare Certified Seattle Sinus Surgery Center and are in attendance for the entire time that the patient is in the surgery center.
Visiting From Out of Town
The Seattle Sinus Surgery Center has many patients traveling from throughout the Pacific Northwest, Eastern Washington and from around the country. When patients are coming from out of town to have their functional endoscopic sinus surgery, there are four hotels located within two blocks of our office Our office administrator can offer assistance with finding a hotel as we do recommend that patients stay in town for at least one week following their endoscopic sinus surgery prior to leaving for home. There will be at least one debridement procedure performed in the sinus area about one week following the surgery.
Appointment and Consultation
The patient’s first appointment will be with Dr. Portuese and if the patient decides to proceed with endoscopic sinus surgery there will also be a preop appointment with one of our nurses, schedule with three weeks of the surgery date. The first consultation is important face-to-face time with Dr. Portuese and lasts about 30 minutes. This time allows the patient the opportunity to ask questions and discover what sinus surgery can and cannot do for them, and also allows Dr. Portuese time to review CAT scans of the sinuses, and examine the nose. CAT scans and allergy testing results will be reviewed and some of the topics that will be discussed are as follows:
- The surgical technique of endoscopic sinus surgery
- Realistic expectations reviewed
- All CAT scans reviewed
- Any allergy testing reviewed
- Medical history
- Physical examination
- General Anesthesia
- The Seattle Sinus Surgery Center
- Pre and post operative instructions
- Common risks, alternatives and relative expectations
- All previous operative notes and records, including the scan and the report of the sinuses
- Previous medical history as pertinent from an anesthesia standpoint
- Recent or past injuries to the nose
- Current breathing problems
- Allergies to any medications
- Prescription medications including herbal supplements and nasal sprays
- All nasal medications
- Followup visits
Additional time will be spent with out office manager and patient care coordinator to discuss scheduling, preauthorization of medical insurance and with our nurse for the pre operative appointment.
Sinus consultation with Dr. Portuese is a very comprehensive review of the patients’ nose and sinuses. This is an opportunity to sit down with Dr. Portuese and discuss nasal and sinus issues and get your questions addressed.
The Endoscopic Sinus Surgery Preoperative Information
When patients have sinus surgery, there are certain medical and laboratory tests that may need to be ordered prior to any outpatient surgery. The physical examination is done by Dr. Portuese, but some patients may also elect to have a more complete, thorough examination done by their family physician. An electrocardiogram (EKG) will need to be performed on men 45 years of age and over and women 55 years of age and over. This is a routine screening to make sure that there are no preexisting heart problems – a requirement of the physician anesthesiologist. Asthmatic patients may need clearance from their pulmonologist and make sure their asthma is under good control with inhalers. Other blood work may need to be performed depending upon individual health history; a complete blood count will be performed on patients who are anemic, potassium level will be done on patients who are taking diuretics and women who are of childbearing age should undergo a pregnancy test one week prior to the surgery to make sure that they are not pregnant at the time of undergoing elective endoscopic surgery. Patients need to also avoid taking any aspirin, vitamin E, ibuprophen, Advil, vitamins and herbal supplements two weeks prior to surgery. These medications interfere with both anesthesia and bleeding. It is also important to stay off these medications for two weeks after the surgery to prevent a nosebleed in the postoperative course. Outpatient surgery such as this requires a responsible caretaker to be with the patient for the first night (24 hours) after the surgery. Patients are not allowed to drive themselves home (or take a cab on their own) because of the effects from anesthesia. The nursing staff from The Seattle Sinus Surgery Center will ask for the caretaker’s name and contact information, as well as who will be taking the patient home from the recovery room.
Endoscopic Sinus Surgery Postoperative Preparations
The recovery period from endoscopic sinus surgery lasts approximately two weeks after the surgery. The first endoscopic debridement of the sinuses is done one week following the surgery. A second debridement is usually performed two weeks following the surgery. After this point, it is acceptable to fly and to get back to routine lifestyle activities such as exercise and walking. For the first two weeks after the surgery it is important that nothing physical be done to raise the heart rate and blood pressure and physical exercise should be stopped, however a light walk is acceptable. It is also suggested that the patient sleep on one or two pillows to keep their head above their heart. This assists in keeping swelling inside the nose down for the first few days of the recovery period. Housework, laundry and grocery shopping should be done at least a week prior to the surgery so that these are not concerns after the surgery. Patients should also make arrangements for their young children to be taken care of for their first day or two following the recuperation phase of endoscopic sinus surgery.
What To Avoid Before Surgery
Medications: It is important to avoid certain medications prior to any surgery, especially the endoscopic sinus surgery. The nose is very vascular and this is done in an effort to reduce the chance of a nosebleed in the postoperative period. Many medications prolong bleeding time and can create a nosebleed. If a nosebleed should occur in the first two weeks , Afrin will be used. If Afrin fails, packing will then need to be placed inside the nose to stop the nosebleed. Medications, including some prescription drugs, vitamins and herbal supplements all contain elements that thin the blood and interfere with anesthesia. Any medications including aspirin, ibuprophen, prescription blood thinners (such as Coumadin and Plavix), Vitamin E, diet pills and all herbal remedies need to be stopped two weeks before any surgery as well. Any patient with high blood pressure needs to have this controlled since high blood pressure can create a nosebleed.
Smoking: It is important to stop smoking two weeks prior to the surgery since it can delay healing in the sinuses. In addition, tobacco smoke is an irritant to the nasal passageway and can slow down the healing process.
It is important to wash the face with soap and water and shampoo hair. We ask that no makeup, wigs or jewelry are worn the day of the surgical procedure. Please leave purses, watches and ear piercings at home and avoid wearing contact lenses.
Patients should avoid drinking or eating anything by mouth from midnight the night before the sinus surgery prior to undergoing sinus surgery – a mandate of anesthesia physicians. This is to prevent any nausea or vomiting during and after the surgery while in the recovery room.
Patients should come to the surgery center in very comfortable clothing such as sweats and a front closure top. Garments should not be pulled up over the face and nose after surgery.
The Day of the Endoscopic Surgery
On the morning of the surgery, Dr. Portuese will review with the patient the surgical plan of what is going to be performed that day, prior to the induction of anesthesia. He will discuss which sinuses are going to be opened, which can include the maxillary, sphenoid, frontal and ethmoid sinuses. Sometimes a septoplasty and turbinate surgery is performed with the sinus surgery and a cosmetic Rhinoplasty can be performed at the same time, if desired.
Patients will also meet with the anesthesiologist from Swedish Medical Center during the preoperative visit on the morning of the surgery. The anesthesiologist will verify that the patient has had nothing to eat or drink since midnight, verify the procedure that is being performed and also verify if there are any reactions to anesthesia from prior anesthetics. The anesthesiologist will ask about certain medical conditions, food allergies, latex allergies or any other allergic reaction to anesthesia. Patients are then brought into the formal operating room. Intravenous lines are usually started in the right arm or hand and a sedative is given to relax the patient. Anesthetic is given through the IV, which puts the patient to sleep. The induction of anesthesia is usually done with propofol and fentanyl. Once the patient is asleep, a very small breathing tube called the Laryngeal Mask Airway is inserted into the mouth to control the airway and is placed on top of the vocal cords. This is left in place during the time of surgery so that blood does not pool down into the back of the throat or get into the bronchus. Patients are breathing on their own under general anesthesia and there is no recollection of the procedure. Anesthesia is much more safe now than it was many years ago due to improvements in technology, the anesthetic and monitoring agents used during the surgery. To ensure a patient’s complete safety, the board certified physician anesthesiologist monitors the patient’s vital functions the entire time during anesthesia. All bodily functions are being maintained the entire time that the patient is in The Seattle Sinus Surgery Center. Typically the equipment monitors the heart rate, breathing, oxygenation and circulation levels of the body and carbon dioxide level being exhaled. These monitors that are employed are using an EKG (which is a heart tracing), a blood pressure cuff to monitor the blood pressure during the procedure, a pulse oximeter (which measures oxygen concentration in the blood stream) and a ventilation monitor which monitors the patient’s own breathing and respirations. Carbon dioxide monitors and temperature monitors are also used during the surgery to closely monitor for patient safety.
Endoscopic Sinus Surgery – The Day of Surgery
The sinus surgery itself will take approximately one hour to perform. During the procedure, the preexisiting anatomy of the nose will determine the length of the procedure along with the amount of polyps that are present and how many sinuses need to be opened. Dr. Portuese will only open the sinuses that are diseased as documented on the CAT scan. He will only perform a septoplasty to improve the functionality of airflow dynamics through the nose when needed and occasionally turbinate surgery is performed for improvement of airflow issues. A cosmetic Rhinoplasty may also be performed if the patient desires cosmetic improvement of the nose.
Dr. Portuese places a local anesthetic inside the nose to help prevent any bleeding. The nasal endoscopes are inserted into the nose passageway and visualization is performed through these scopes. Natural windows into the maxillary sinuses are enlarged and scopes employed during the procedure have a 0, 30 and 70 degree angles on them so that Dr. Portuese is able to visualize around the corner while doing the endoscopic sinus surgery. The polyps are generally removed at the ostiomeatal complex, which is a very common area for polyps to occur. The ethmoid sinuses, when opened, will consist of unroofing the bottom portion of the anterior and posterior ethmoid sinuses, along with removing polyps located within them. The frontal recess and frontal sinus duct is opened up and the anterior-most portion of the ethmoid area. The opening of the duct is verified through the endoscopes with a 70 degree endoscope. This is the hardest sinus to open – located at the top of the nose above the eyes. The natural window into the sphenoid sinuses is also enlarged with a pediatric upbiting wheeled Blakesley forceps. All tissues blocking sinus drainage are conservatively removed through the functional endoscopic sinus surgery techniques. Surgicel is placed in the ethmoid area to control bleeding.
Once all of the diseased sinuses have been opened and polyps removed, Dr. Portuese removes the instruments from the nose. There are no sutures placed inside of the nose for sinus surgery. If there is a septoplasty performed at the same time, two dissolvable sutures are place inside the nose. As soon as the anesthetic is turned off by the anesthesiologist, patients wake up and are taken to the recovery room where they spend about an are prior to being discharged.
Postoperative Recovery – Two Weeks
Patients recovering from their endoscopic sinus surgery typically take at least two weeks for the swelling to come down on the inside of the nose. There is no swelling, and usually no bruising on the outside of the nose or face. Dr. Portuese will presecribe a moderate strength pain reliever such as Vicodin, during the first two to three weeks in the postoperative phase. The pain that is involved with sinus surgery is variable; in the typical postoperative course, patients have varying degrees of facial pain and pressure, and headaches for the first couple of weeks. The pain may feel as if they have a very bad sinus infection, and most patients will have some form of discharge from their nose that can mimic a sinus infection. At one week post op, an endoscopic debridement is performed in the office under topical anesthesia. Patients are sprayed with Afrin nasal spray to open the nasal passageways and then a topical anesthetic (Pontocaine) is sprayed inside the nose. This numbs the tissues while Dr. Portuese does some “housecleaning” which is the debridement procedure. The debridement itself is uncomfortable and we suggest a pain medication taken one hour prior to the appointment. The debridement is done once at the first week and again the second week. At this stage, patients are beginning their recovery process and feeling and breathing much better. Headaches and the facial pain and pressure are usually beginning to subside at this point. Full healing after endoscopic sinus surgery is usually one month, however, patients will return for a one year follow-up for Dr. Portuese to check their progress. Many patients have much fewer symptoms and sinus infections after their surgery, however, approximately 20% of all sinus surgery patients will need some type of secondary procedure on their sinuses because of the regrowth of the polyps within ten years following the initial sinus surgery.
Complications That Can Occur With Sinus Surgery
There are a few complications that can occur with endoscopic sinus surgery; there is a one in a thousands chance of having a severe nosebleed and if this should occur, Afrin is applied to the nose. If this does not stop the nosebleed after an hour, a small packing will be placed on the side that is affected. On a rare occasion, both sides can be bleeding and packs would then be placed on both sides of the nose and left in place for two days. Another complication that can occur from endoscopic sinus surgery is a leak of brain fluid from the nose. A small crack can occur in the bone high in the ethmoid area which allows the leak of brain fluid to come through the nose. This is noticed by a patient leaning over and literally having water draining out of the nose as if it were a faucet. If this should occur, a secondary surgery to patch the crack will have to be performed. The chance of having a CSF brain fluid leak is approximately one in a thousand in Dr. Portuese’s hands. Meningitis is also extremely rare following the surgery and no one knows the mechanism of how this may occur. Permanent blindness or double vision has never occurred in Dr. Portuese’s hands and is exceedingly rare.
In conclusion, the endoscopic sinus surgery performed by Dr. Portuese at The Seattle Sinus Surgery Center is a very rewarding experience for both the surgeon and the patient. Patients are grateful that they no longer have their typical chronic sinusitis symptoms of headaches and facial pain and pressure, and they are breathing freely out of their nose and have their sense of smell improved. Dr. Portuese has performed this procedure on professional chefs and winemakers which has literally changed their careers because they had no idea they had lost their sense of smell. Patients tend to do very well from this surgery but do need to take the postoperative time for healing and recovery.
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