Sinusitis is a common condition that may affect many people during their lifetime. There are two types of this condition, acute and chronic sinusitis. In acute sinusitis, the patient has severe symptoms that last for about a week only. The symptoms usually occur following a cold which changes to ‘green/yellow’ discharge, with severe pain around the cheeks and occasionally the eyes and forehead. Some patients also get referred toothache. Chronic sinusitis continues for many weeks, and can result after an attack of acute sinusitis that has not settled down completely. It can also occur due to untreated allergies, air pollution, chemical irritants, and structural problems in the nose such as deviation of the nasal septum. The symptoms are milder than in acute sinusitis. Patients often complain of nasal congestion as if they have a “permanent cold” with some nasal discharge and/or mucus in the back of the throat (post nasal drip). Some patients have heaviness or pressure in the cheeks, around the eyes or forehead.
Acute sinusitis is treated with antibiotics and decongestants, and usually settles down quickly with a very rare need for surgery. Chronic sinusitis requires long-term treatment, which can include antibiotics, steroid nose sprays or drops, and antihistamines if needed. In the majority of cases of chronic sinusitis, the patient will improve on medical treatment, but occasionally patients will require surgery.
Injuries of the nose account for some of the most common facial injuries. The injuries can cause damage to the skin, bone or cartilage or any combination of these. Cuts of the skin are usually treated in the accident and emergency department with either sutures or self-adhesive strips, and the patients are given Tetanus prevention vaccination if they were not already immune. Fractures of the nasal bones will lead to a lot of swelling which may take up to five days to settle down enough for the bones to be examined. This is the reason most accident and emergency departments will delay referral to Ear, Nose and Throat surgeons, until five days have passed since the injury. If the nasal bones are fractured, they will need to be repositioned under general anaesthesia within fourteen days of the injury, before they have set. X-Rays do not add to the diagnosis unless there is suspicion of other facial fractures. If the bones are not repositioned after fourteen days, the patient may need the nose to be re-fractured under anaesthesia for the bones to be re-set a few months later, and this may include a full operation known as a Rhinoplasty. If the cartilage of the nasal septum was also affected by the injury, this will lead to nasal obstruction, and often further deviation of the nose itself. For this to be corrected, the operation of a Septorhinoplasty may have to be considered, after the swelling has settled down.
Most patients do initially complain of some nasal blocking because of the entire swelling, which is not necessarily due to a fracture of the cartilage of the nasal septum. It is important however, to be aware that patients who have complete obstruction of the nose may have developed a haematoma, a collection of blood between the layers of the nasal septum, which needs to be urgently dealt with. Most patients also do have some bleeding from the nose, which will settle down gradually.
Very rare complications of nasal injury include loss of sense of smell or cerebral spinal fluid leak. A cerebral spinal fluid leak is when the thin bone of the roof of the nose fractures, leading to leaking of the fluid that surrounds the brain.
Nasal polyps are swellings of the lining of the sinuses, due to inflammation. They usually originate from the ethmoid sinuses, which are the small rooms that line the sides of the cavity of the nose. They contain fluid and inflamed lining, but no particular reason as to why people develop them has been found. However, they seem to be associated with some conditions, and are known to be more common in patients with asthma and those with aspirin hypersensitivity. Polyps may enlarge gradually and lead to some nasal blockage with a decrease in the sense of smell. If they enlarge further, and completely fill the cavity of the nose, the patients would have no sense of smell and their nose would be completely blocked. Because of their content, they also lead to excessive nasal secretions.
Nasal polyps will usually shrink when nasal steroid sprays or drops are used for treatment. When the polyps are very large, the patient would often need steroid tablets. Most patients will need to continue with the steroid sprays or drops for many years, to keep the polyps controlled. This is a safe method of treatment, as very little of these steroids are absorbed into the body and only work locally within the nose. This does not apply to steroid tablets, which should only be given for short periods of time. Some patients will still complain of symptoms if their polyps do not respond to the treatment and will need surgery. Surgery for nasal polyps improves the nasal breathing and may decrease the recurrence of the polyps. However, recurrence can still happen in up to 70% of patients. For this reason, patients are advised to continue with the topical steroid sprays or drops after the surgery.
Tumours of the nose are very rare, and are mostly benign. The most common being inverted papilloma, which is a ‘warty’ slow growing tumour similar to nasal polyps that causes nasal blockage. Other rarer tumours include haemangioma, osteoma, and ossifying fibroma which are all very rare. Most of these cause symptoms when they are large enough to lead to nasal blocking. Some will cause nasal bleeding, especially in the case of a haemangioma. If a tumour blocks the sinuses, this can lead to sinus infection which in turn causes sinus pain, but otherwise tumours are painless. Other symptoms can include facial swelling, and even double vision. The majority of these benign tumours are treated by endoscopic surgery, with no need for facial incisions.
Malignant tumours of the nose are even rarer than the benign tumours, but can present with similar symptoms. A diagnosis would be based on clinical examination and tests which include scans and biopsies. Treatments for these tumours vary according to the type of the tumour.
CSF is the fluid that bathes the brain and is normally separated from the cavity of the nose by the bone of the roof of the nose and sinuses. Most cases of CSF leaks through the nose occur after major accidents where this bone is fractured, leading to a tear of the protective lining of the brain, with leakage of the fluid. Fortunately, the majority of these cases settle on their own, but occasionally surgery is required to repair these. Leaks also very rarely occur during sinus surgery if the bone at the roof of the sinuses has been injured.
Spontaneous CSF leaks can also occur, but quite rarely. These are associated with conditions such as idiopathic intracranial hypertension (IIH) where there is a high pressure inside the skull, which eventually leads to the creation of small holes between the nose and the brain, with the result being that of leakage of the fluids. Spontaneous CSF leaks are often associated with the presence of meningocoeles or encephaloceles in the nose where portions of the lining of the brain or sometimes even small pieces of the brain itself, can push through the small holes into the nasal cavities. The main risk of this condition is the possibility of contracting meningitis, which is an infection of the linings of the brain. Because this is a serious condition, it must be treated by surgery through an endoscopic procedure to repair the holes.
Patients with this condition often have one-sided drainage of clear watery discharge, which increases on bending over or on exercise. Some people, especially those with increased intracranial pressure, will have blurred vision, headaches, ringing in the ears and dizziness.
The nasal septum is mainly made of a thin piece of cartilage and bone inside the cavity of the nose between the right and left side. It separates the nostrils, and is the reason why we have two cavities inside the nose. In some people the septum can be bent into one or other of the sides, blocking it. Sometimes this is caused by an injury to the nose, although occasionally it just grows this way from birth. In some cases, especially where the septum is severely deviated, the nose itself will be bent to one or either side.
Surgery for the nasal septum is done to relieve the blocking of the nose. The operation known as a Septoplasty is done through the inside of the nose to straighten the septum which will improve the nasal breathing. Occasionally this operation is done in patients that are undergoing other procedures, such as sinus surgery to create room to improve access. The operation is not meant to change the shape of the nose, but in the cases of a twisted nasal structure the operation of a Septorhinoplasty may be necessary to straighten the nose itself. The operation of a septoplasty, as mentioned previously, is done inside the nose and will take from 30 to 45 minutes. It is mostly done under general anaesthesia. The cuts are made inside the nose to take away some of the cartilage and bone, straightening the rest of the septum and then stitching it back into position. Rarely complex cases require a cut through the skin between the nostrils, and may be combined with a Septorhinoplasty. Most patients do not need any packs or splints unless a full septorhinoplasty was carried out.
Septal surgery is safe, but as with any surgical procedure there are always some risks. Occasionally the nose can bleed excessively after the operation, and in this case patients will require packs to be inserted inside the nose to stop it. Rarely, the patient may even need to go back to the operating theatre and have anaesthetic to stop the bleeding.
Infection of the nose is rare after the operation, and if this does occur the patient will get more blocked and sore. This will need to be treated as this can in turn cause serious problems.
Rarely the operation can lead to a hole in the septum inside the nose, which can often cause a ‘whistling’ sound when you breathe. It can also cause crusting, blockage or occasional nose bleeds. However, most of the time holes in the nose do not cause any problems and are left alone. If they do cause problems, further surgery to repair the holes is necessary.
Very rarely, the shape of the nose itself may change slightly, leading to a dip in the bridge of the nose. Most of the time this would be difficult to notice, but if it is noticeable it can be fixed with further surgery. Other rare symptoms such as numbness in the teeth can occur, but usually settles within a few months.A FESS is the abbreviation of Functional Endoscopic Sinus Surgery. Patients that have chronic sinusitis that has not settled using medication, often require a FESS procedure. The operation is designed to enlarge the natural drainage holes from the sinuses into the nose, which helps to clear the infection and prevent further attacks. This is also required in patients with nasal polyps, which is a different condition from sinusitis. Patients with polyps often continue with nasal sprays or drops after the surgery to prevent recurrence of the polyps.
The operation is done under general anaesthesia, although it can be done under local anaesthetic. The procedure is all carried out inside the nose using a small endoscope attached to camera assistance. There is no need for any incisions, unless the operation is very complex, in which case this would be discussed with you before the surgery.
Dressings that dissolve by themselves are placed inside the nose which do not need to be removed, and will take approximately two weeks to dissolve. The first few weeks, the patients are advised to blow their nose gently or it may start bleeding, and they are also advised to sneeze with their mouth open, in order to protect the nose. Patients would be given a salty water spray or liquid on leaving the hospital, to help clear the nose. Patients will often get blood coloured watery fluid from the nose, which is normal. It is common for the nose to be quite blocked and perhaps with some discomfort, for a few weeks after the operation. A course of antibiotics may be prescribed, and the patients are recommended to avoid dusty and smoky places. The lining of the sinuses will take at least six weeks to heal during which the nose may still feel ‘stuffy’. Any discomfort can be relieved with simple painkillers.
All operations carry some risks, and these are normally discussed with patients prior to the surgery. Potential complications that can happen after endoscopic sinus surgery are very uncommon. These include the risk of heavy bleeding, which is uncommon in itself. It is however very common for patients to have some bleeding from the nose after the operation, but major bleeding is rare and would require management with packing, and occasionally a return to the operating theatre.
Because of the proximity of the eye socket and the brain to the sinuses, potential complications in this area do exist, but they are extremely rare. The bone that separates the sinuses from the eye sockets and the brain is very thin, and if injured this can lead to these complications. Sometimes only minor bleeding can occur which leaks into the eye socket and this is usually noticed as bruising around the eyes. This is usually minor, and will settle without treatment. More serious bleeding into the eye socket is very rare, but it can cause risk to the eye sight and will require immediate drainage. Leakage of the cerebrospinal fluid can occur if the thin bone between the brain and the sinuses is injured. This is very rare and if it does happen it will need to be repaired, and the patient will be required to stay in Hospital for longer than expected. However, studies have shown that the risk of significant complications to these structures is less than 0.1%.
A Rhinoplasty is an operation to change the shape of the nose. The type of operation depends on which areas of the nose need to be corrected. Various changes can be made to the nose, such as straightening, decreasing the size or removing bumps. The shape of the tip of the nose can also be changed, and in some occasions the nose can be made bigger. Occasionally pieces of cartilage of bone may be removed from or added to the nose to obtain the necessary results. Sometimes the nasal septum, which separates the nostrils, can be twisted and needs to be straightened at the same time, which is known as s septorhinoplasty. This is often done in combination to correct a twisted nose, or to improve breathing.
The operation aims to give a balanced and well-proportioned nose that suits particular facial features of the patients. Every nose is different, and it is not advisable to try to obtain a nose that is similar to another person. It is important that the patient who wishes to go ahead with a rhinoplasty is aware of the limitations of surgery, and has realistic expectations as to what can be done.
Some factors can affect the result of the surgery. The thickness of the skin is an indication of how the nose would look after surgery and what can be done. If the skin is thick, not all changes that can be made on the cartilage or the bone will show on the outside. If the skin is thin, it makes irregularities or bumps difficult to hide. Various techniques are used to overcome these limitations, although it is not always possible for the surgeon to say exactly how the nose will look after the operation.
Most Rhinoplasties or Septorhinoplasties can be done without any facial incisions. In some patients however, it is necessary to create a small incision in the skin between the nostrils to get better access to the nasal tip and the rest of the nose. This is usually needed in complex and revision cases. Occasionally, some cartilage is taken from the ear or the rib to add to the cartilage of the nose. This will not change the shape or function of the ear or the ribs. Sometimes synthetic material such as, absorbable PDS plates or soft Permacol are used for further support and refining of the structure of the nose.
All the incisions are normally closed with absorbable stitches, except for when there is an external incision in the skin which would be closed by stitches that need to be removed a few days later. The patient normally leaves the Hospital with a plaster that is taped to the skin around the nose. Packs are only rarely inserted, in cases where there is excessive bleeding from the nose.
The nose would be tender for a few weeks, but the operation itself is not known to be very painful, and normal painkillers should help. Some patients may get blood coloured watery fluid or mucus coming from the nose for the first two weeks or so, which is normal. The nose would be blocked on both sides like a heavy cold, for about two weeks after the operation and maybe longer. Patients are also given drops or sprays to help with this. If cartilage was taken from the ear or the rib, this would be sore for a couple of weeks, and most patients will be fine taking simple painkillers if they are needed.
It may take up to three months for the nose to settle down and for the breathing to start clearing again. Any stitches inside the nose will usually dissolve by themselves. The bruising and swelling around the nose and eyes usually settles within two weeks, although sometimes this can take longer. Fine swelling may take up to a year to settle down completely, at which time the final result of the surgery can be judged. Following the rhinoplasty or septorhinoplasty, the skin of the nose is very sensitive to the sun and it is therefore important to apply strong sunscreen for three months after the surgery. The nose can also feel a little stiff and numb around the tip for up to three months or maybe longer.
As with any surgery complications can occur during or after a rhinoplasty, although they are uncommon. Excessive bleeding can happen within the first few hours or up to ten days after the surgery. This usually settles down with simple measures, although very occasionally some patients will need to go back to the operating theatre and have anaesthetic, to control the bleeding. Infection of the nose is rare after the surgery, but if it does happen it can cause problems. Very rarely if a septorhinoplasty is done, a hole can be left within the septum which can cause problems such as, whistling, crusting and bleeding. If this occurs, patients may need to return to theatre in order for the hole to be repaired. Although, most of the time these holes do not cause any symptoms and are left alone. Very rarely, patients are left with some numbness around their teeth, which usually settles down within a few months after surgery. Up to 10% of patients may need another operation to further adjust the shape of the nose.
The tears are produced by a gland at the corner of the eye, called the lacrimal gland. These are normally drained through small canals within the eyelids that connect to a larger canal called the nasolacrimal duct, which drains the tears into the nose. In some people the nasolacrimal duct can get blocked either due to infection or the duct just gets narrowed over the years. Traditionally, surgery has been carried out to bypass this canal through an incision on the skin of the corner of the nose, which can leave a small scar. Alternatively, an operation has been developed to create this opening using endoscopes through the inside of the nose. This allows the surgeon to make an incision in the lining inside the nose, and therefore does not leave any scarring. The surgery is done jointly with a Consultant Ophthalmologist, and is called a DCR (Dacryocystorhinostomy). The aim of this surgery is to create an alternative tear flow pathway directly above the nasolacrimal duct into the nose. It is done under general anaesthesia, and takes between 30-45 minutes. Normally packs are not necessary inside the nose, and small tubes are left inside the canal through the eyelid, which are almost imperceptible. These are normally removed after eight weeks at the outpatient clinic. Occasionally, it is necessary to straighten the nasal septum during the same operation, to improve the space inside the nose and the result of the operation. This will not change the external shape or structure of the nose. There is often a small amount of nasal bleeding for the first few days after the surgery, which settles down gradually. The patient would also have some nasal blockage, and some discharge which will take a few days to a couple of weeks to settle.
Complications of surgery are uncommon, but can include heavy bleeding which needs further management by packing. Infection can also occur, but it is also very uncommon and would cause increasing pain within the nose. Damage to the eye or vision is extremely rare as the surgery is done within the nose.
90% of patients are very pleased with the result of surgery with complete drainage of the tears.
