May 24, 2017

When is Sinus Surgery Appropriate for Recurrent or Chronic Sinus Infections?

Normal CT Sinus Scan
When a patient suffers from chronic or recurrent sinus infections, sinus surgery is an option to consider especially when medical management has failed. There are the obvious candidates where any reasonable ENT would agree sinus surgery is required, but as with much of medicine, there are times when a patient may get several diametrically opposite opinions whether sinus surgery is recommended or not.

Such opposing recommendations at its core occur due to what a CT scan of the sinuses show.

To begin, let's start with a representative case of a patient who has suffered from chronic recurrent sinus infections. This patient reports 6+ sinus infections per year over the past 5+ years. This patient has been on a number of antibiotics including amoxicillin, augmentin, cefdinir, z-pack, and levaquin along with oral steroids, daily saline flushes, oral allergy medications, and steroid nasal sprays.

First, let's talk about the obvious sinus surgery cases.

On physical exam, large nasal polyps are seen with pus pouring out of the sinuses. A CT Sinus scan obtained shown below reveals sinus cavities that are completely opacified indicating profoundly diseased sinuses. (Black indicates air just like the black around the head. Anything but black indicates something other than air in the sinus cavity, presumably sinus disease.)

Unlike the normal CT Sinus scan at the top, note that the
sinus cavities are completely greyed out.
I would warrant that 100% of ENTs would recommend sinus surgery in this particular situation.

However, WHAT IF the nasal endoscopic exam was essentially unremarkable AND the CT Sinus scan obtained came back completely normal as shown below? Again, the same exact patient history as stated above.

Normal CT Sinus Scan
In this scenario, a patient may get different recommendations if they pursued several different ENT opinions. Some ENTs would recommend sinus surgery based on history in spite of normal exam and CT sinus scan. The argument being that it just happened to be normal on the day of the examinations. The analogy being, if a child has a history of 7+ strep throat infections in the past year, but the exam happened to be normal on the day he sees an ENT, tonsillectomy and adenoidectomy would still be recommended.

However, the majority of ENTs (myself included) would argue against sinus surgery in spite of the history. Why?

The counter-analogy I use in this scenario is an abscess of the skin. A surgeon would cut open the skin ONLY IF an abscess is present in order to "release" the pus (incision & drainage or I&D). Sinus surgery is kind of like that, but it's the sinus rather than the skin... As such, doing sinus surgery with a normal CT Sinus scan is like cutting open the skin when no abscess is present... for example, if only a rash or cellulitis is present, neither of which is a reason to cut open the skin.

Furthermore, based on clinical criteria alone, sinus infections are notoriously difficult to diagnose. Sinus infections can be confused with viral infections, allergies, and even deviated septum with enlarged turbinates.

Typically, an aggressive workup is pursued beyond a CT scan and endoscopic exam to evaluate all other possibilities on the assumption that the patient may have been misdiagnosed with recurrent sinus infections when the symptoms were actually due to something else. My favorite statement being,
"maybe the antibiotics did not work for your sinus infections because you never had a sinus infection in the first place."
What does this workup entail?

Allergy testing and if positive, AGGRESSIVE allergy management including even allergy shots. (Sometimes, if the allergies are bad enough, taking just one allergy medicine is inadequate. One may need to take several allergy medications.)
• Evaluate for large inferior turbinates or deviated septum that may cause persistent symptoms of nasal congestion and feeling stuffy. Treatment would be turbinate reduction and septoplasty... not sinus surgery.
• Evaluate for possible immunodeficiency. It just may be that the patient is getting recurrent infections, but not because of any underlying sinus anatomic issues, but because the immune system is much weaker than normal leading to the inability to fight off infections as easily as someone with a normal immune system.
• Miscellaneous considerations include neurologic (trigeminal migraine, contact point headache, etc) as well as autoimmune abnormalities.

If and only if this workup comes back normal and the patient continues to get bona fide sinus infections that are culture positive, sinus surgery can potentially be considered even if the CT Sinus is normal. However, in just this type of scenario, it may be worthwhile to get a 2nd opinion just to ensure nothing got missed.

Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids.

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