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The nasal sinuses are interconnected spaces in the skull that are lined with respiratory tissue (mucosa). These sinuses range in size from several centimeters to only a few millimeters. Every sinus has an opening that allows the sinus to drain to the inside of the nose. The sinuses are shown below.
All sinuses are paired. The maxillary sinuses are the largest sinuses and located below the eyes in the cheeks. The frontal sinuses are in the frontal bone in the forehead. The ethmoid sinuses may have three to ten separate bony cells on each side and are found between the eyes behind the top of the nose. The sphenoid sinuses (not shown here) are at the back of the nasal cavity in the middle of the head.
The left and right sinuses and nasal cavities are divided by a wall of cartilage and bone called the nasal septum. When the nasal septum becomes shifted and causes significant symptoms, this can cause what is known as a deviated septum and may require surgery. The turbinates are ridges of bone covered with mucosa and are located on the lateral walls of the nasal cavity from the front to the back of the nose.
The surfaces of the sinuses and the inside of the nose are covered with a very specialized mucosa. This mucosa has tiny scrubbers called cilia that direct the flow of mucus and dirt from the sinuses into the nasal cavity and to the back of the throat where it can be swallowed. A sticky layer of mucus coats the cilia and prevents particles and bacteria from getting into the sinuses. One liter of mucus is made per day to help keep the sinuses clean. The mucosa of the nose helps to warm and humidify as well as purify the air we breathe.
The maxillary, frontal and anterior ethmoid cells drain through a common channel called the “osteomeatal complex” which is located in the anterior nasal cavity. The posterior ethmoids and sphenoid sinuses drain into the posterior nasal cavity.
Swelling or obstruction of the nasal mucosa for any reason may prevent the sinuses from draining normally. When bacteria or viruses are not being cleared from the sinuses and stagnate, they can multiply, cause pus with more inflammation, and become a sinus infection (sinusitis). Because the connecting channels inside the nose may only be a few millimeters or less, even a small amount of swelling can cause sinusitis. A common cold lasting greater than several days may be undiagnosed sinusitis.
The reasons for mucosal swelling and potentially bacterial sinusitis are numerous. Allergies, irritation of the nose by inhaled dust, a viral infection, drinking alcohol, dry air, headaches, perfume, smoke, stress, and spicy foods, to name a few. Narrow anatomy of the nose can predispose to sinus infections. This can include a deviated septum, turbinate hypertrophy, thickened mucosa, nasal polyps, and abnormally thin sinus channels.
A deviated nasal septum is when the bone or cartilage dividing the middle of the nose is twisted to the left or right. The deviation has to be severe enough to cause symptoms. Enlarged turbinates, or turbinate hypertrophy, occurs when the mucosa or bone of the ridges on the lateral sides of the nose blocks airflow. These conditions can prevent normal mucus draining from the nose which can cause sinusitis. They also can cause snoring, sleep apnea, and nasal obstruction.
Causes of sinusitis include:
Thick nasal drainage – During sinusitis, the mucus from the nose may be yellow or green colored, have a bad odor, and be thicker and more copious than normal.
Headaches, facial, dental or sinus pain – The pressure of the pus pushing on the delicate nasal and sinus passages can cause severe headaches, cheek and forehead pain, and toothaches especially in the back upper teeth.
Worsened nasal obstruction and congestion – Inflammation and swelling in the nose and sinuses will block airflow and the natural drainage pathways of the sinuses. There may be baseline congestion from a deviated septum or inferior turbinate hypertrophy that is magnified by the swelling of a sinus infection.
Fatigue – Your body uses a lot of energy when it is fighting an infection, which explains why you may feel weaker or have trouble focusing when you are sick. Sleeping can also become more difficult due to post nasal drip and nasal obstruction.
Decreased sense of taste or smell – The sense of smell requires that nasal mucosa be functioning properly. Anything that congests the nose will decrease one’s sense of smell. Our sense of smell is what allows our taste buds to be able to pick up the subtleties from food or drink. When we are unable to smell normally, food often tastes bland, or like nothing at all, making meals less enjoyable or even reducing your appetite.
A mild case of sinusitis may be resolved either with no treatment or through an over-the-counter (OTC), prescribed medication. A more severe, acute sinus infection can be treated with an antibiotic that addresses the most common bacterial causes of infection. Additional improvement may be obtained by a combination of antihistamines, oral and topical decongestants, steroid nasal sprays, saline rinses and environmental controls. Failure of maximal medical management may require additional testing including a nasal endoscopy or a sinus CAT scan to look for the causes and location of the infection.
After appropriate medical management has failed, having sinus surgery may be needed to decrease, minimize, or eliminate the occurrence of sinus infections. A functional endoscopic sinus surgery (FESS) opens obstructions inside the nasal passages to allow each sinus to be aerated and drain through its natural or surgically-made sinus opening. Straightening the deviated nasal septum (septoplasty), and reducing the inferior turbinates (turbinoplasty), may be required as well to improve breathing and ventilation to the sinuses. The deviated cartilage and bone of the deviated septum and the thickened bone and mucosa of the sinuses can be removed using microinstruments and high-powered endoscopes. The procedures take about an hour or two at an ambulatory surgery center and usually require general anesthesia. You will go home about an hour after surgery.
Dr. Bennett individualizes every patient’s care. A minimum of half an hour is needed to fully understand your expectations and to get a complete history and evaluation of the inside and outside of your nose. Knowing what to expect will make the entire experience more pleasant and increase your satisfaction with the surgical results. Dr. Bennett will discuss the cosmetic and functional expectations of your surgery in detail to make sure all of your questions are answered. Depending on whether you have functional/breathing issues insurance may cover part of your surgery.
Functional endoscopic sinus surgery (FESS) is an option for patients when other medical treatments have failed. The surgery seeks to restore normal function to the sinuses and limit recovery time. The surgery addresses each individual sinus and removes the blockages to allow each sinus to be ventilated and drain through its natural opening. Polyps and scar tissue are removed along with thickened mucosa to improve sinus function. All procedures are performed through the nostrils. Straightening a deviated nasal septum (septoplasty) or reducing enlarged turbinates (turbinoplasty) at the same time may improve the results of sinus surgery. Insurance will almost always cover the cost of sinus and breathing surgery.
Dr. Bennett uses the most advanced sinus surgical techniques available. He does not pack the nose. He finds that the placement of nasal packing and associated discomfort is rarely needed. No packing in the nose improves the overall experience and allows for a more rapid recovery. A headache for a couple of days and nasal congestion for at least the first week are common. Patients will generally return to normal activity in 7-10 days.