Breathe Easy—Sinus Surgery Works

Three-quarters of patients who have undergone surgery for stubborn sinusitis saw significant and lasting improvements in their quality of life, according to recent research.

Most of the remaining 25% also saw some improvement, just not as dramatic, said Timothy L. Smith, MD, lead author of a study appearing in the journal Otolaryngology-Head and Neck Surgery.

"Certainly this reinforces our belief that sinus surgery increases the quality of life of patients, and I see that clinically as well as scientifically," added Jordan S. Josephson, MD, a sinus and allergy specialist in private practice in New York City. "Previous studies have been single-center studies, and this is a bigger study using multiple centers and using a fairly large population, so it further says sinus surgery is a really good thing to do if you need it."

Surgery For Chronic Sinusitis

Chronic rhinosinusitis (CRS) affects a sizable minority-14% to 16%-of US residents. The condition, marked by symptoms such as sinus pain and pressure, headache, stuffy nose and sneezing, can compromise quality of life more than congestive heart failure, back pain or chronic obstructive pulmonary disease, the study authors said.

Endoscopic sinus surgery has been performed in the United States since the mid-1980s, said Dr. Smith, who is director of the Oregon Sinus Center at Oregon Health & Science University in Portland.

It's a minimally invasive type of surgery performed with a fiber optic scope that goes into the nostril, then basically snips away abnormal and interfering tissue while leaving normal tissue behind, Dr. Smith explained.

Study Details

Dr. Smith and his coauthors studied 302 patients with CRS from three academic medical centers, following them for an average of a year and a half after their surgery.

"These were patients who have chronic sinusitis so, by definition, they have at least three months of symptoms and they have evidence of an ongoing inflammation or infection of their nose and sinuses on either a CT scan or an examination of the nose and sinuses," Dr. Smith said.

Following the surgery, about 76% of patients had "clinically significant" improvement in quality of life, as measured by various validated scales.

Patients with worse disease at the outset seemed to fare the best after the procedure, as did those undergoing surgery for the first time. This second finding is probably explained by the fact that people going for second or further surgeries were probably sicker to begin with Dr. Josephson said.

Advice

"I don't think it means everyone with CRS should consider surgery. They should try medical therapy, and if medical therapy fails and the surgeon feels that their problem can be helped by surgery, then surgery would be a good tool for them to use," Dr. Josephson said. "Some people with milder disease may even get cured. This is a wonderful renewed hope of feeling better."

New Help for Chronic Sinus Infections

Chronic sinusitis is the most common long-term disease in the US. Even though more than half of all cases of sinusitis clear up on their own within two weeks, about 40 million Americans develop the chronic variety.

What happens: The sinuses, four pairs of cavities in the skull that filter and warm air as it passes through the nose on its way to the lungs, are lined with mucus-producing tissue. The tissue typically produces more than a quart of mucus a day, which drains through tiny holes into the back of the throat. When these holes are blocked, mucus can't drain properly. The holes often become blocked when the tissues swell during an allergy flare-up or an upper-respiratory infection.

Result: Facial pain, headache, fatigue, nasal and ear congestion, postnasal drip, cough, snoring, nosebleeds and a reduced sense of smell or taste, along with other cold-like symptoms. As mucus accumulates, it provides an optimal environment for bacterial or fungal growth. The resulting infection can further irritate and inflame sinus tissues.

Do Antibiotics Work?

Sinusitis is defined as "chronic" when it lasts for more than four weeks or keeps coming back. For many patients, sinusitis is a lifelong disease. The symptoms may come and go, but the underlying problems persist. Patients need to manage it daily just as they would any other chronic disease, such as diabetes or arthritis. A total cure is unlikely-but with the right medical treatment, patients can expect a significant improvement in quality of life.

A short-term course of antibiotics usually will eliminate a case of acute sinusitis (assuming that the infection is bacterial), but this rarely works for chronic sinusitis.

Reason: Most cases are multifactorial. Patients with a bacterial infection might simultaneously harbor viruses or mold, organisms that aren't affected by antibiotics. A Mayo Clinic study found that 93% of all chronic sinus disease cases are caused by fungus (mold) found in the nasal passages. The mold can cause persistent infection. Even in the absence of infection, mold spores can stimulate an allergic reaction that causes persistent congestion.

Antibiotics can make a difference in patients with chronic sinusitis, but only when they are used for three to eight weeks. The same is true of anti-fungal sprays or oral drugs. Long-term therapy (up to three months) usually is required.

Recommended: Regardless of the underlying cause, most patients can get some relief with prescription steroid nasal sprays. Decongestants (oral or spray) also can be helpful but should not be used for more than 48 hours without your doctor's OK. Nasal irrigation is among the best ways to promote mucus drainage and relieve sinusitis symptoms.

Daily Care

Every patient with a history of chronic sinusitis needs to be alert to lifestyle factors that increase congestion and symptom flare-ups. Important…

• Track your diet. Even patients without clear-cut food allergies may find that they produce more mucus when they eat certain foods, such as dairy or foods with gluten or certain sugars, including high-fructose corn syrup. I advise them to keep a food diary for a month or more. Write down everything that you eat and drink, and make a note when your sinuses feel worse. When you suspect that a certain food is causing problems, give it up for a few weeks and see if you feel better.
  
• Take control of allergies. They are among the main triggers for sinusitis. When you have an allergy flare-up-whether from pollen, animal dander or anything else—treat it promptly with an antihistamine to keep mucus from building up.
  
• Blow your nose gently. Blow one nostril at a time. This is more effective than blowing both at once.
  
• Clean your house and car. Any area that's moist, such as the bathroom or under the refrigerator, can harbor mold spores that irritate sinus tissues. Clean these areas well with soap and water or a commercial mold-killing solution. Don't neglect your car. Cars trap humidity as well as heat, both of which encourage mold growth. Keep the seats and dashboard clean.
  

Sinus Surgery

Some patients may require surgery to restore normal drainage. Endoscopic sinus surgery (sinoscopy) is now the standard approach. A thin tube is inserted through the nostrils. Surgical instruments are used to remove blockages and sometimes to remove bone to enlarge the sinus openings. The procedure is done in an operating-room setting. Typically, you are home that night and back to work the next day with minimal discomfort that rarely requires more than Tylenol.

Recently, surgeons have added balloon sinuplasty to the procedure. A guide wire is used to position a deflated balloon inside the sinus openings. Then the balloon is inflated, which enlarges the openings and promotes better drainage, without removing tissue. It is appropriate in only about 10% or fewer of total cases-usually those involving a less severe condition.

Important: Most patients improve significantly after surgery, but few achieve a total remission of symptoms. Most still will need occasional help from steroid nasal sprays, decongestants, etc.

Nasal Cleanse

Irrigating the nose once or twice daily is among the best ways to improve sinus drainage. This helps relieve symptoms, and it also can prevent sinusitis from getting started.

A neti pot (available at most pharmacies and health food stores) is an effective irrigation tool. It's an ancient Indian device that has a tapered conical tip at the spout end. You also will need saline solution. You can buy prepared sterile saline from most pharmacies, but large quantities may require a prescription from your doctor (some insurance companies will cover this). Or you can make your own saline. Bring eight ounces of distilled water to a boil, add one-quarter teaspoon of salt to the water, and let the mixture cool to room temperature.

Fill the pot with the cooled saline, Tilt your head to one side, and gently insert the spout of the neti pot into the raised upper nostril. Continue to breathe through your mouth, and slowly pour the saline into your upper nostril. The saline should pour through the upper nostril and out the other lower nostril into the sink (you also can try this in the shower).

When you're done, compress one nostril at a time by placing pressure on it with your finger and then blow your other nostril by exhaling firmly several times.

Then reverse the tilt of your head and repeat the process on the other side by pouring saline into the other nostril.