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The sinuses
are air filled spaces in the skull. Most people do not realize these
spaces exist in the skull until a problem develops, and they begin to
experience the symptoms of sinusitis.
There are
four pairs of sinuses - one pair over the cheeks (maxillary), forehead
(frontal), between the eyes (ethmoid), and a last pair deep in the
center of the head (sphenoid). The sinuses are connected to the nose,
and nasal cavity by way of small openings called ostia. Except for the
ethmoid sinuses between the eyes, the other sinuses are poorly developed
at birth. They normally commence development in later childhood to
attain their adult size at the onset of puberty.
Interestingly, no one fully understands the purpose for the existence of
the sinuses. One explanation is that the sinuses, being air filled
spaces, cause the skull to weigh less than if it had consisted of solid
bone. Another reason may be that the sinuses act as a protective buffer
zone in injuries of the face, by preventing force from being transmitted
to the vital structures in the skull. Whatever its benefits, one thing
is for sure - the sinuses can be the cause of a lot of trouble.
Individuals
who do not have a particular sinus will not develop sinusitis in that
area. For example, ten percent of people in the general population will
have small underdeveloped frontal sinuses. This makes it impossible for
them to suffer from the severe headaches of frontal sinusitis.
Mr. Warren
first realized how troublesome sinusitis can be when he first contracted
the infection two years ago. The symptoms first started as a flu, which
caused a blocked nose, runny nose, and pain over the cheeks. The pain
got worse, and reached a crescendo 3 days later, when it was so painful
that he was unable to go to sleep. He would wake up in the mornings
feeling that he had not slept at all. The pain of the cheeks has also
extended to involve the forehead, and the top of his head. By this time,
his nose was s blocked that he had to open his mouth to breath. He would
wake up the next day with a very dry, and sore throat. Furthermore, he
could not enjoy his meals as his sense of smell, and taste had gone.
Initially he thought that the symptoms would go away in a week. However,
when the symptoms continued to persist, and his ability to work was
affected, Mr. Warren became desperate.
Over the next
few months, he went around consulting many different doctors and was
given a myriad of different medications. One of the doctors he consulted
decided to perform an endoscopic examination of his nose, and found some
swelling on the side wall of both noses. He went through a computed
tomographic scan (CT scan) which demonstrated that he had sinusitis of
both his maxillary and frontal sinuses. Sinus surgery was performed
under general anesthesia. One week later, his symptoms of pain, sore
throat, and inability to smell had disappeared. Since then, he has been
enjoying very restful and peaceful nights of sleep. Fortunately, many
people suffer from sinusitis, but few need surgery for resolution of
their symptoms. Most sinusitis can be treated with medications like
antibiotics, decongestants and antihistamines. Others may need simple
outpatient procedures like a washout of their sinuses to flush away the
pus and to open up the sinus ostia.
Allergy
The most
common cause of sinusitis is allergic rhinitis (allergy of the nose),
which accounts for up to 80% of sinusitis cases. The allergic response
occurs as a result of an over-exaggerated response by the body's immune
system to substances that enter the body from the outside environment.
The reaction causes the lining of the nose to become inflamed, and swell
up (rhinitis), resulting in obstruction of the sinus ostia, and poor
drainage of the sinuses. Secretions build up, acting as a good growth
medium for bacteria, allowing them to flourish in an unimpeded fashion
within the sinus. Pus forms, and accumulates under pressure, allowing
some of it to squeeze, and escape through the narrowed ostium into the
nasal cavity. This gives rise to the yellow nasal discharge that is seen
in sinusitis.
Sinusitis can
have a variety of other causes. The common final pathway by which all
these other diseases cause sinusitis is through obstruction of the sinus
ostia resulting in poor sinus drainage. Thus, deviation of the nasal
septum, foreign bodies, cancer and nasal polyps can cause obstruction to
the sinus ostia, giving rise to sinusitis. As allergic rhinitis is the
most common cause of sinusitis, it is imperative that an allergic
process is assumed, and the offending allergen searched for in all cases
of sinusitis. The allergen, or the substance that causes allergy, can
come into our bodies through the air that we breathe in or from the
foods that we eat. Inhalant allergens, or the allergic substances that
we are exposed to in the air, is tested very simply through a blood
test. This is sent to an allergy laboratory for analysis.
Testing for
food allergens, however, can be a little bit more cumbersome. This is
because food allergens are tested using a series of skin tests, which
may require half a morning or more for its completion. If the offending
inhalant or food allergen is identified, and the appropriate treatment
measures taken, a dramatic improvement in sinusitis usually occurs,
obviating the need to medications, antibiotics and surgery.
In those
patients who are unable to benefit from anti-allergic measures, and
medications, surgery becomes an important consideration in management.
The most simple form of surgery is a sinus washout done under local
anesthesia in the outpatient setting. The check sinuses are irrigated to
wash out pus within the sinus, and to open up the ostia by forcing the
irrigation fluid through it. Other procedures include the Caldwell-Luc
operation which involves opening up the cheek sinuses through a hidden
incision underneath the upper lip. With the recent advent of the
Hopkin's endoscopic rod, we are now entering a new era of improved
visualization of the body's interior, and minimally invasive key-hole
surgery. The endoscope enables us to make more accurate diagnosis of the
causes of sinusitis, and to identify new disease processes which could
not have been identified before. It has also enhanced our ability to
perform sinus surgery by peering through the nostrils instead of having
to make unsightly facial incisions.
The new sinus
operation that is done through the endoscope is called Functional
Endoscopic Sinus Surgery (FESS), pronounced "fest" as in "food-fest". It
is an operation that is done on the sinuses using an endoscope with the
objective of restoring normal function to the diseased, and obstructed
sinuses. Since its debut into the medical world in the 1970s, its has
been gaining widespread popularity among Ear Nose Throat Surgeons
worldwide. This stems from the fact that many surgeons recognized the
great leap forward that Functional Endoscopic Sinus Surgery (FESS)
enabled them to make. Functional Endoscopic Sinus Surgery (FESS) gave
surgeons the power to see, and operate better in the little confined
spaces of the nose, and sinuses to achieve the objectives of diseases
resolution and symptom improvement in an more effective way.
Many new
refinements have also been made with Functional Endoscopic Sinus Surgery
(FESS) surgery. In the past, FESS surgeons had to peer directly into the
endoscope by leaning over the anaesthetized patient lying on the
operating table. Surgeons tired out easily as they were operating in an
uncomfortable, and awkward position. Many began to develop neck ache
from the many hours straining the neck during FESS surgery. Nowadays,
doctor are doing their operations through a video attachment to the
endoscope that allows surgeons to look at a video monitor. It is less of
a physical strain. The Functional Endoscopic Sinus Surgery (FESS)
surgeon can spend a longer time on the operation without tiring out.
This translates into increased safety, and better outcomes for the
patient.
Another
refinement is to use a microdebrider during FESS surgery. The
microdebrider is a surgical instrument that works like a hybrid between
a vacuum cleaner, and a grass cutter. The cutter chops off unwanted
abnormal tissues while the vacuum cleaner sucks it away from the area of
operation. The microdebrider has the advantage of allowing the surgeon
to remove diseased tissue in a precise manner, cutting it sharply,
without tearing, and shearing that would have occurred with conventional
sinus surgery instruments. This reduces unnecessary damage to the sinus
tissues, resulting less scarring, and better healing.
During
surgery, blood accumulation in the operating site cause blurring and
reducing visibility with potentially disastrous consequences. Especially
in the enclosed confined spaces of the sinuses, complications resulting
from such a lack of visibility is exponentially magnified. The
microdebrider allows timely, and 'on-line' removal of blood, and tissue,
keeping the operation site clean so that the Functional Endoscopic Sinus
Surgery (FESS) surgeon can proceed safely, and smoothly under conditions
of good visibility.
What about
the laser? Does it offer any benefits or advantages in Functional
Endoscopic Sinus Surgery (FESS) ? Unfortunately, while the laser is
indispensable in certain procedures, the tongue for instance, it has no
real advantage in sinus operation. In fact, the laser may actually
increase surgical risk when used in conjunction with Functional
Endoscopic Sinus Surgery (FESS). It may cause inadvertent laser burns,
and damage to important nearly structures around the sinuses, like the
eye, brain and carotid vessels.
Functional
Endoscopic Sinus Surgery (FESS) is still in the process of evolving.
Controversy, and changing opinions continue to characterize its present
state of knowledge. It will be quite a long time more before all the
relevant issues are sorted out for it to become a "mature" operation.
The medical world is till on the learning curve with newer, and better
instruments and techniques coming onto the market in an attempt to
improve patient safety and surgical outcome.
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