Advanced Sinus/Skull base

Problems of the nose and sinuses can dramatically affect a patient's quality of life. Staffed by fellowship-trained ear, nose and throat doctors and other specialists in allergy and immunology, the Advanced Sinus and Skull base Center provides a comprehensive approach to managing nasal and sinus disorders. Our physicians are dedicated to providing the highest level of care to patients with complex sinonasal disorders. The physician(S) emphasize comprehensive strategies that combine both medical treatments and sinus and nasal surgery.

Specialized treatment is provided for patients suffering from nasal and sinus diseases and complications, including:

• Acute and chronic sinusitis and its complications
• Nasal polyps and allergy
• Neoplastic disease
• Reconstructive problems
• Septal deformities and other problems leading to nasal airway obstruction
• Sinus surgery after prior unsuccessful therapy

What is the skull base?

The skull base is the undersurface of the brain that is separated by bone between the facial structures of the ear, nose and throat. The common areas are situated within the paranasal sinuses and mastoid regions.

What do Rhinologic and Endoscopic sinus/skull base surgeons do?

At ENTA, members of the Rhinology and Skull Base Center:

• Evaluate and treat sinus and nasal disorders on an in-office basis
• Perform Surgical Repair in the areas of:
  • Sinus: Infections and tumors (benign and malignant)
  • Nasal Septum and Rhinoplasty* (* AFP division also)
  • Nasal Fracture; Sinus fractures
  • Skull Base: Endoscopic CSF leak repair
  • Skull Base: selected brain tumors removed endoscopically through the nose

What is Functional Endoscopic Sinus Surgery (FESS)?

FESS is surgery performed to unblock congested sinuses, and it is usually reserved for those patients who have already failed medical treatment and/or have anatomical blockages which predispose them to infection. Procedurally, a small rod with light and camera (endoscope) is passed into the nose to look inside the nasal and sinus passageways. Small instruments are then used to remove any blockages that are discovered. (These instruments are designed to cut and shave on a very fine level, thereby avoiding tearing away the normal lining of the nose and sinuses). Commonly a deviated nasal septum is corrected at the same sitting. The procedure usually takes place at an outpatient facility either at the hospital, freestanding facility or doctor's office. Anesthesia is generally required-preferably general anesthesia or twilight sedation-and the recovery period is about one week; two weeks from heavy exercising. Certain circumstances allow for local anesthesia only, should minimally invasive techniques be appropriate (see balloon office sinus dilation).

What are Sinuses?

Our sinuses are spaces which contain air, and produce mucous to cleanse the nose and upper respiratory tract. There are four sinuses located on each side of our face…specifically the cheek or maxillary, eye or ethmoid, forehead or frontal and the back of the nose sinuses called the sphenoid sinuses. All have small openings that drain mucous into the nose. The average human being produces about one to two liters of mucous a day, which is swallowed without interference with regular activities. However, when these openings are blocked due to a swelling from a cold, virus, allergy or polyp the sinuses retain the mucous.

What is Sinusitis, and what are the Symptoms?

When mucous becomes trapped inside the sinus, it gets infected with the bacteria that normally live in the unsterile nose (and discolors to green from its normal clear, white or yellow hue). This infection causes pressure and pain as the mucous fills the sinus. In turn the nose swells, so breathing is difficult and interferes with our sleep. The mucous (or phlegm) also drips into the throat causing sore throat, throat clearing, cough, hacking, "lump in throat" sensation and even fatigue with fevers. One can even lose our sense of smell and taste.

What are Treatments for Sinusitis?

The good news is that most sinus infections go away by themselves. However, due to the discomfort and ‘quality of life interference’ caused by this nose, sinus and allergy condition, a lot of people require medical treatment. Simple remedies are saline sprays, washes and irrigations. Decongestants like Sudafed help congestion. Antihistamines aid allergic symptoms of seasonal sniffling, postnasal drip, itchy eyes, nose and throat. When these fail, a visit to a physician is required to determine if antibiotics are needed to treat a bacterial sinus infection. A topical steroid spray may be required if the condition is chronic or felt to be secondary to an allergic condition. The term “acute sinus infection” indicates symptoms are less than three weeks in length, while “Chronic sinusitis” refers to a condition that lasts longer than three months. “Acute recurrent” is a form of chronic sinusitis where the interval periods are completely clear between episodes. Typically, there are three to four episodes a year with interval free periods between episodes.

What are the Various Sinus Treatment Alternatives?

1. OVER THE COUNTER TREATMENTS:
   • Normal Saline spray, wash, irrigation (Neilmed sinus rinse, Neti Pot
   • Sudafed or antihistamines (Claritin, Allegra, Zyrtec, Xyzal, Clarinex)
   • Mucolytics: Mucinex, Mucinex D, Mucinex DM
2. PRESCRIPTIONS REQUIRED:
   • Topical Nasal Steroid Sprays (Flonase, Nasonex, Nasacort, Veramyst, Qnasl and Omnarus Singulair
   • Topical Nasal antihistamines: Astepro, Patanase, Dymista (azelastine and fluticasone)
   • Antibiotics: Augmentin, Levaquin, Clindamycin, Septra/Bactrim, Tetracycline, Avelox, Z-Pak (for mild or allergic problems)
   • Oral steroids (medrol dose pack, prednisone)
   • Evaluation by an allergist
3. OTHER THERAPIES:

   If medical therapy fails-meaning symptoms continue despite antibiotic treatments-and maintenance medications above are without benefit, a CT scan of the sinuses without contrast is obtained. Based on a patient’s history of chronic sinusitis, as well as an examination and CT scan evaluation, a recommendation for FESS is made. However, based on very recent advances in medical therapy, another option besides FESS is may now be available to some patients. Specifically, a sinus specialist may recommend opening your sinuses with an inflated balloon. This minimally invasive procedure can be performed right in the doctor’s office, under a local anesthesia. As a result, this option is both far less intrusive and provides the patient with a far quicker recovery. It should be noted that patients with massive nasal polyps are not candidates for this in-office procedure since polyps need to be removed. A severely deviated nasal septum may also be a relative contraindication to the transnasal balloon but these patients may benefit from the oral approach under the lip. It is best to discuss these options with your doctor.

4. BALLOON OFFICE PROCEDURE

   As discussed above, one recent option to FESS is in-office balloon sinus dilation performed under local anesthesia. While awake, under topical and local anesthesia, a balloon is passed into the natural opening of the three sinuses. The balloon is inflated and then deflated and removed. A microfracture is made around the sinus opening of the maxillary, frontal and sphenoid sinuses keeping the sinus open. Studies have shown that patency rates are 90% with over a year follow-up. The advantages of the balloon treatment include less bleeding (since there is no tissue removal), quick recovery (usually 24 hours) and less postoperative discomfort. Patients who are not candidates for general anesthesia such as COPD, asthmatics, morbid obesity, sleep apnea, cardiac risk and patients who have not tolerated general anesthesia in the past, may benefit from this procedure.

5. SEPTOPLASTY (correction of deviated nasal septum)

   The internal wall between each nostril is made up of cartilage and bone. If it is crooked and blocking the nasal passage way, it is called a deviated nasal septum.

6. RHINOPLASTY

   Rhinoplasty is the correction of outside nasal deformities. This repair is usually performed for either cosmetic reasons or as the result of trauma. Recent trauma, which has significantly changed the shape of the nose, may require a closed reduction (manipulation of the nasal bones) or a more formal operation six weeks later (open reduction). Frequently, a deviated nasal septum is repaired due to breathing problems at the same time. Cosmetic rhinoplasty is commonly performed in girls starting at age 14. In boys, it is commonly performed after the ages of 15 to 16 years old, so most of their growing will have been completed. Participation in contact sports also plays a role in timing of the operation. Recuperation is usually about five to seven days but physical activities are off limits for at least two weeks. Contact sports are to be withheld for at least six weeks so the bones heal properly.

Does Insurance Cover Rhinoplasty?

Cosmetic Rhinoplasty is an uncovered medical expense and is not medically necessary. This means surgery will NOT be covered by third party payers (insurance companies). Frequently, patients who undergo cosmetic rhinoplasty have medically necessary surgery performed simultaneously to correct a deviated nasal septum for breathing problems. Partial coverage may apply, but out of pocket expenses will be applied for services considered cosmetic or medically not necessary. Functional Rhinoplasty, generally performed as the result of recent trauma, may be covered by insurance (if it is deemed medically necessary). Most commonly coverage is the result of well-documented trauma (car accident, sports injury). At ENT & Allergy Associates, patients receive a thorough review of documents, photos are taken and the appropriate imaging (CT scans) tests are ordered and reviewed. This helps substantiate the medical necessity of the procedure.

What about Nasal Fractures?

Here’s some medical trivia for your next social gathering. Guess which is the most commonly fractured (broken) bone in the human body? The nasal bone.

What about Nasal and Sinus Tumors?

Over 90% of the time, endoscopic sinus surgery is performed for benign chronic inflammatory disease like chronic sinusitis and nasal polyps. However, tumors or growths-benign and malignant-can be found inside the nasal and sinus cavities. These, in turn, require removal and/or biopsy. The most common benign tumor is inverted papilloma. Inverted papilloma usually grows on one side, tend to recur despite removal in at least 20% of cases and can undergo a malignant change 7-19 %. Complete removal and follow-up surveillance is required. Malignant tumors are less common but could occur. Biopsy is deployed to confirm the diagnosis. Malignant tumors are squamous cell carcinoma, nasopharyngeal carcinoma, adenocarcinoma, mucoepidermoid, adenoid cystic, melanoma, esthesioneuroblastoma, lymphoma, sarcoma and midline granuloma. When these tumors grow beyond the sinuses they could invade the orbit (eye) and/or the skull base just in front of the brain.

What about Endoscopic and Skull Base/Endoscopic Pituitary Surgery?

Most nasal and sinus tumors can be safely and completely removed endoscopically through the nose avoiding external incisions. Skull base tumors, especially pituitary tumors, which comprise 10% of all brain tumors, can be removed in this manner. Some skull base tumors require the collaboration of co-surgeons from two different surgical services. The rhinologic endoscopic surgeon partners with a neurological surgeon colleague to remove brain tumors through the nose. The most common procedure performed is removal of pituitary tumors from behind the sphenoid sinus. Other types of surgical cases involve repairing CSF leaks, removal of encephaloceles (brain tissue herniating through a crack in the skull base), craniopharyngiomas, chordomas, meningiomas and cervical spinal cord decompression. All of these procedures combine trans-nasal endoscopic skull base surgery with image-guided, computer-assisted surgery. This type of surgery has enabled quicker recovery, more complete tumor removal due to the optics of the scope being able to look around the corners.

What about repairing CSF Leaks and Sinus Fractures?

Transnasal endoscopic repair is the best method to close most cerebro-spinal fluid leaks, which present with CSF rhinorrhea (watery discharge from one side of the nose).

What are the symptoms of Sinusitis?

Sinusitis can have varying symptoms, and it is valuable to recognize them all. These may include:

• Pain over sinuses
• Purulent drip
• Nasal congestion
• Discolored mucous
• Inability to smell
• Low grade fever
• Cough
• Phlegm in throat
• Fatigue for greater than three month