How Does Sinusitis Surgery Work?

(Prof. Dr. Gediz Murat Serin – Ear Nose and Throat Specialist, Teşvikiye ENT)

Sinusitis often begins with a simple cold, flu, or allergy attack; however, as the process prolongs, it can turn into a condition that seriously impairs quality of life with nasal congestion, postnasal drip, head and facial pain, loss of smell, and frequent infections. One of the permanent solution options that comes up in cases of sinusitis attacks that do not improve despite prolonged medication treatments is endoscopic sinus surgery, or as it is commonly known, sinusitis surgery.

In this article, as an ENT specialist who has been performing endoscopic sinus surgery in Istanbul for many years, I will try to explain the questions “How is sinusitis surgery performed, who needs it, what can you expect during and after the surgery?” in both an understandable and scientifically sound manner.

Which Patients Need Sinusitis Surgery?

We do not recommend surgery to every sinusitis patient. Many patients can recover without the need for surgery through properly planned medication, nasal sprays, saline rinses, and allergy control.

Sinusitis surgery mostly comes up in the following situations:

• Chronic sinusitis lasting more than 12 weeks
• Frequently recurring sinusitis attacks requiring antibiotics each time
• Polyp (tissue growth) formation inside the nose
• Permanently blocked natural drainage pathways of sinuses visible on sinus CT scan
• Continuation of complaints such as loss of smell, facial and head pain, postnasal drip, difficulty breathing despite medical treatment
• Frequent bronchitis or lower respiratory tract infection attacks due to sinusitis

In short:
If medications, nasal sprays, saline rinses, and allergy treatment have been applied regularly for a certain period of time; yet no clear improvement has been achieved, endoscopic sinus surgery comes up to permanently correct the drainage and ventilation of the sinuses.

Pre-Operative Evaluation: Not Just CT Scan, Endoscopy is Essential Too

When planning sinusitis surgery, I definitely apply three basic steps:

1. Detailed History

• How long the complaints have been ongoing
• Which medications you have used and for how long
• Previous nose/sinus surgeries you have undergone
• Accompanying diseases such as allergy, asthma, aspirin sensitivity
• Smoking, reflux, occupational exposures

All of these play a critical role in helping me understand whether sinusitis is just an infection or related to a broader underlying problem.

2. Endoscopic Nasal Examination

I evaluate the inside of the nose in detail with magnification using thin optics (endoscopes). This way I can directly see:

• Whether there are polyps inside the nose,
• Which areas and which sinuses the inflammation has affected,
• The condition of the turbinates (nasal tissues),
• Whether the septum (nasal middle wall) is deviated, perforated, or has a constricting effect

3. Sinus CT Scan

The sinus CT scan is the map of the surgery. With CT:

• Which sinuses are blocked
• The condition of thin bone structures
• Anatomical variations (narrow areas, additional cells, narrowed sinus ostia)

are evaluated in detail. I create the surgical plan step by step based on these CT sections.

In conclusion:
When detailed history + endoscopic examination + sinus CT scan are combined, and the chronic sinusitis diagnosis is clear and the medical treatment limit has been reached, I openly discuss with you the pros, cons, risks of sinusitis surgery and what you might face in the medium to long term if you do not have surgery. We definitely make the decision together.

What is Endoscopic Sinus Surgery (ESS / FESS)?

Today, what is meant by sinusitis surgery is mostly Endoscopic Sinus Surgery (ESS / FESS). It has shown significant development over the past 40-50 years and has become the gold standard in chronic sinusitis treatment today.

The main goals of endoscopic sinus surgery:

• Widening the natural drainage openings (ostia) of the sinuses
• Enabling re-ventilation of the sinuses
• Cleaning polyps and inflamed tissue if present
• Reactivating the mucociliary system (the sinuses’ own cleaning mechanism)
• Facilitating the penetration of sprays and saline rinses into the sinuses

This surgery is not a procedure that “hollows out and destroys” the sinuses; on the contrary, it is a functional surgery that opens blocked pathways and makes the sinus system functional and breathing again.

Thanks to developing technology:

• High-resolution cameras
• Endoscopes with different angles (0°, 30°, 45°, 70°)
• Very thin instruments specific to sinus surgery
• Navigation (surgical GPS) systems for necessary patients

make it possible to open sinuses both more safely and in a more controlled manner.

The navigation system allows us to use the 3D map of the pre-operative CT scan during surgery. This system especially:

• In patients who have previously undergone sinus surgery (revision)
• In cases with distorted anatomy, polyps or tumors
• In areas adjacent to the eye, skull base, optic nerve and major vessels

both increases safety and allows us to perform more complete surgical cleaning.

How is Sinusitis Surgery Performed?

Today, sinusitis surgery is largely performed from inside the nose, that is, with endoscopic sinus surgery (ESS / FESS). There is no incision or scar from the outside of the face.

1. Anesthesia

Sinusitis surgery is usually performed under general anesthesia.

• During the surgery, you won’t feel, see, or hear anything.
• When you wake up, the entire procedure will be completed.

2. Camera Entry Through Nostrils

During surgery:

• I enter through the nostrils with thin endoscopes.
• The image is magnified like a surgical microscope and projected onto the screen.
• This way, I can see even the narrowest passages of the sinuses clearly.

Many procedures that used to be done with facial incisions can now be performed from inside the nose and in a much more controlled manner.

3. Opening the Natural Drainage Pathways of Blocked Sinuses

One of the main purposes of the surgery is not to “scrape out” the sinuses; but to reopen the natural drainage channels and provide permanent ventilation-drainage.

During surgery:

• Polyps and edematous/inflamed tissues are cleaned.
• The narrow region connecting the sinuses to the inside of the nose (ostiomeatal complex) is opened.
• Depending on the situation, the entrances of the maxillary, ethmoid, frontal and sphenoid sinuses are widened.
• Closed, non-ventilated sinuses are opened to the inside of the nose with a wide window without disrupting the anatomy.

This way:

• Inflamed secretions inside the sinus can drain easily,
• Air entry and exit improves,
• Topical medications (spray, rinse) can reach inside the sinus,
• In the long term, significant reduction is achieved in complaints such as pressure, pain, frequent infections.

4. Septoplasty and Turbinate Procedures in the Same Session

In a significant portion of chronic sinusitis patients, sinusitis is not the only problem. Frequently accompanying structural problems such as:

• Septum deviation (nasal middle wall curvature)
• Turbinate hypertrophy (enlarged turbinates)

are found. In this case, in the same session with sinusitis surgery:

• Septoplasty (correction of the nasal middle wall)
• Turbinate reduction (radiofrequency, microdebrider or endoscopic turbinate surgery)

I aim to permanently improve both sinus drainage and nasal airway.

How Long Does Sinusitis Surgery Take?

The duration of surgery varies depending on the extent of the disease, the number of sinuses involved, the presence of polyps, and accompanying septum/turbinate procedures:

• Limited sinus involvement patients: average 1-2 hours
• Polyp and multi-sinus cases: average 2-3 hours
• If there is advanced septum surgery, rhinoplasty or additional procedures in the same session, the duration may be even longer.

These durations are average; they may be shorter or longer from patient to patient. After surgery, I take most patients to their room the same day and discharge them the same day or the next day depending on their general condition.

Is Packing Used in Sinusitis Surgery?

The classic, thick gauze packs that completely fill the nose and make breathing almost impossible have been largely left behind in modern sinus surgery.

In the current approach, most of the time I prefer to use:

• Silicone splints that allow air passage or
• Special dissolvable gels inside the nose that control bleeding

This way:

• Post-operative breathing is more comfortable,
• The pack removal process is much more comfortable compared to past bad experiences.

If silicone splints are used, they are usually removed in a controlled manner within 1-3 days.

Recovery Process After Sinusitis Surgery

First Days

In the first days after surgery:

• Nasal congestion,
• Mild facial swelling and headache,
• Occasional pink-bloody nasal discharge

may occur and these are mostly normal findings we accept. Simple painkillers are usually sufficient.

During this period, for a while I recommend avoiding:

• Heavy exercise and lifting weights,
• Very hot showers, hamams and saunas,
• Sudden forward bending

Nasal Cleaning and Check-ups

In the success of sinusitis surgery, post-operative care is as important as the surgery itself.

Therefore:

• I perform endoscopic check-ups at regular intervals to gently clean crusts and clots inside the nose,
• I give you a saline (physiological serum) rinse program to apply at home and nasal sprays if necessary.

During this period, saline rinses play a critical role in preventing the opened sinus pathways from becoming blocked and closed again.

Between 1-3 Months

As the weeks after surgery progress:

• The inner surface of the sinuses heals,
• Ventilation and drainage become stable,
• The frequency and severity of sinusitis attacks, antibiotic needs, facial pain and pressure sensation significantly decrease in most patients.

If you have allergic constitution, smoking, reflux or other accompanying factors, controlling these is extremely important for the long-term success of the surgery.

Does Sinusitis Surgery Have Risks?

As with any surgical intervention, endoscopic sinus surgery also has some risks; however, with correct indication, good planning and an experienced surgeon, these risks are quite low.

Possible risks include:

• Post-operative nasal bleeding
• Formation of adhesions (scar tissue) inside the nose
• Rarely infection
• Infrequently swelling and bruising around the eyes
• Very rarely, unwanted situations related to eye structures or cerebrospinal fluid

During your pre-operative examination, I evaluate the expected benefits for you together with these risks and we make the decision together.

Does Sinusitis Surgery Solve Everything Completely?

In properly selected patients, sinusitis surgery performed with the correct technique:

• Frequent infections,
• Long and repeated antibiotic courses,
• Constant nasal congestion, facial pressure and headache complaints

are greatly reduced and often quality of life is significantly improved.

However, there is one point to remember:

• The sinuses remain in place; we open the doors.
• Factors such as allergy, smoking, reflux, immune problems, septum deviation, turbinate enlargement can feed the sinusitis condition.

Surgery corrects the anatomical problems of the sinuses; but if these accompanying factors are not controlled, mild complaints may occasionally recur in later years.

Therefore, it is more accurate to see sinusitis surgery as one of the most important and permanent steps of the treatment process when applied to the right patient at the right time.

Conclusion: Sinusitis Surgery is a “Path Opening” Operation Performed From Inside the Nose, Without Leaving Scars

In summary:

• Sinusitis surgery is a modern and functional surgery performed with a camera from inside the nose, aimed at opening the natural drainage pathways of the sinuses.
• The goal is not to remove or destroy the sinuses; but to create a sinus system that can breathe again and clean itself.
• In the right patient, after surgery easier breathing, fewer infections, more comfortable sleep and higher quality of life are possible.

If you also have:

• Sinusitis complaints that have not resolved for a long time,
• Frequent sinusitis attacks despite medications,
• Sinus blockage detected on CT scan,

we can evaluate your condition with detailed endoscopic nasal examination and sinus CT scan if necessary and plan the most appropriate treatment option for you together.