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Why do some sinus procedures fail?

Most people have friends, family, or personal experiences with failed sinus procedures. Symptoms were better for a while, and then slowly returned to how they were before their procedures. This leads to skepticism when any doctor, no matter their training or expertise, tells them that a procedure is needed to improve their sinus health long-term. It can be a barrier to trusting any sinus doctor or even seeking out needed care.

These are three important factors that determine the long-term success of treating chronic sinusitis:

1. Underlying disease

Most patients with chronic sinusitis have an inflammatory disorder causing swelling, irritation, and increased mucous production within their sinuses and nasal cavities. This may be triggered by significant allergies to particles in the air (pollen, mold, dust mites, etc.), poor immune system function (low antibody levels, immunosuppressing medications for other illnesses, etc.), and other immune system factors (high eosinophil levels, high IgE levels, production of thick mucous that cannot drain, etc.). Less challenging cases have causes that can be eliminated, such as an infected maxillary molar causing sinusitis.

2. Challenging anatomy

No two patients are exactly alike in the anatomy of their nose and sinuses. Each sinus cell within the ethmoids and along the frontal sinus drainage pathway can impact how easy it is to get the ethmoid and frontal sinuses opened adequately. Thin bones around these openings are easier to remove or displace with a balloon, and result in larger openings. Thick bone can significantly reduce the size of a sinus opening if a surgeon is not prepared to use the full variety of instrumentation available, and in a balloon sinuplasty would prevent adequate dilation of a sinus. When bone is poorly developed over important structures such as the orbit, skull base, optic nerve, or carotid artery, these structures may be at increased risk for complications if a surgeon has inadequate training or experience. Heavier bleeding during polyp surgery may limit a less skilled surgeon from performing the extent of surgery needed for long-term relief.

3. Knowledge and surgical skillset of the treating physician

Comfort level in making larger sinus openings varies tremendously among ENT physicians performing sinus surgery. Those with little exposure to frontal drillouts (enlarging the frontal sinus drainage pathway using a curved drill through the nostril) are unlikely to attempt these procedures once out of training. Similarly, extended maxillary and sphenoid openings and truly complete ethmoidectomies are often not done unless the ENT physician pursued additional training in these techniques. Even basic sinus surgery without extended openings may be performed with minimal tissue removal (surgeon able to successfully probe a small sinus opening, opening only the lower portion of the ethmoid sinuses, and ongoing poor visibility into most sinuses once complete). These surgical limitations are, unfortunately, very common and significantly limit the ability to manage chronic sinusitis without additional surgery. Appropriate surgical intervention by a well-trained sinus surgeon overcomes the challenges of patient anatomy and provides the degree of sinus visibility and openness necessary for ongoing management regardless of a patient’s underlying disease process.

The long-term success of a sinus procedure depends upon an accurate assessment of the underlying disease causing the sinusitis, appropriate extent of surgery to allow for ongoing treatments within the sinuses if needed, and ongoing monitoring and treatment of the medical aspects of chronic sinusitis. This may include daily nasal sprays or nasal irrigations containing topical steroids, allergy immunotherapy (shots or drops), ongoing antihistamines to reduce allergy symptoms, or other medications that address specific problems with someone’s immune system. Surgery does not cure inflammatory disorders. It is extremely successful in improving quality of life and success of treatment when used in addition to appropriate medical therapy to treat chronic sinusitis.

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