With the ongoing globalization, the prevalence of allergic diseases is increasing. The one obvious cause is pollution. Allergy, especially nasal allergy leads to sinusitis which often needs surgery. Despite advanced instrumentation and diagnostic modalities like high resolution computed tomography (HRCT), surgical failure happens but why. Let’s understand Why sinus surgery fails.
Background on Sinus Surgery
There are certain cavities inside a person’s skull—located around the eyes, nose, and within the front of the face. These cavities are hollow spaces lined by mucosa and get ventilated when we breathe. These cavities or sinuses are located between eyes (ethmoid sinuses), behind and above eyebrow area (frontal sinuses), behind your cheeks (maxillary sinuses), and in the back of your nose (sphenoid sinuses). These sinuses help in making the skull lighter and produce mucus (a protective layer to keep unwanted particles away) that adds moisture to the nasal passages.
Other functions of sinuses are to act as cushions, make the skill lighter, provide resonance to our voice, etc.
Need of Sinus Surgery/When do you need sinus surgery
The procedure of sinus surgery aims to open the drainage pathways of the sinuses and remove whatever is blocking the drainage pathways of the sinuses.
Some of the sinus surgery may include clearing or removing:
- Thin pieces of bone
- Mucous membranes
- Nasal polyps
- Swollen or damaged tissue
- Tumors or growths blocking the nasal or sinus passage
People may require sinus surgery to treat a variety of issues. However, if possible, the doctor generally tries out other treatments before resorting to surgery. If other procedures or treatments don’t work, surgery may be carried out.
Sinus surgery is required to treat some of the following medical issues:
- Someone suffering from sinusitis and nasal polyps
- Someone having nasal infections or ongoing blockages
- Someone with ongoing and recurrent sinus infections
- Someone with abnormal sinus structure
- Someone with abnormal growths in the sinus
- Someone with other issues that cause inflammation in the nasal passages and sinuses
Reasons why sinus surgery fails
As with any surgical procedure, sinus surgery has its associated risks. Despite technological advancement in instrumentation, imaging, as well as an understanding of the pathophysiology of some diseases, failure of endoscopic sinus surgery remains an important problem.
In most cases, the most common causes of surgical failures of the sinus are residual disease in air cells (sinuses) and adhesions (synechia formation when the unhealed skin surfaces attach to each other and cause blockage) in the ethmoid area, maxillary sinus opening, frontal sinus ostium (or opening). Other causes can be
- Separate maxillary sinus ostium stenosis
- Remnant frontal recess cells
- A retained uncinate process
- Middle turbinate lateralization
- Scarring or inflammatory mucosal thickening
- Recurrent polyposis
Recurrent mucosal disease retained ethmoid air cells, and lateralized middle turbinate were the most common factors, while missed frontal cells, scarring, and neo-osteogenesis were also found to contribute.
Factors determining the outcome of sinus surgery
There are many other critical factors required for a successful surgical outcome of sinus surgery. These can be divided into pre-surgical, surgical and post-surgical
Why sinus surgery fails-pre surgical factors
- History of a disease (such as polyp recurrence) – Natural history of a disease can be perceived especially by the patient as a surgical failure.
- Inaccurate interpretation of sinus CT images – Familiarity with the complex anatomy of the frontal recess revision surgery and knowledge is essential including reviewing images in multiple imaging planes, which otherwise can cause surgical failure.
- Inaccurate radiologist report – Accurate report should accurately characterize any frontal recess cells present by using standard accepted nomenclature.
- Lack of meticulous planning – Challenging cases often require meticulous preoperative planning and thorough time-consuming dissection. Non-adherence to such factors leads to incomplete and ineffective surgical execution.
- Lack of pre-operative counseling to patient – It is critical to discuss the difficulties of the underlying disease with the patient.
- Poor patient selection – It is a key issue, particularly in the difficult area of facial pain. There is a need to select patients for surgery who have a reasonable likelihood of post-operative symptomatic improvement.
- The presence of systemic diseases like immune deficiency – May contribute to a poor result.
- Lack of time – Complex cases involve devoting an appropriate amount of time to a specific patient’s operation. In many cases, it may not easily be achieved within the confines of a busy operating list crammed with multiple patients.
- Repeated functional/option-meatal complex surgery – It has little prospect of success, especially as it has been executed unsuccessfully on earlier occasions. In such a patient group, more extensive surgery may need to be considered.
Why sinus surgery fails- surgical factors
- Surgical technique – Good surgical results requires good equipment, appropriate surgical skills, and the. In many sinus surgeries, these critical requirements are missing.
- Technical factors – It continues to play an important role in a failed surgery. Computed tomography (CT) of the paranasal sinuses has become indispensable in the evaluation of patients with FESS failure (especially in the frontal recess), a location that can be difficult to visualize at endoscopy.
- Lack of working knowledge of surgical failures – During revision surgery, ensure to have a working knowledge of the most common causes of surgical failure in the frontal recess. This includes remnant frontal recess cells, a retained uncinate process, middle turbinate lateralization, osteogenesis, scarring or inflammatory mucosal thickening, and recurrent polyposis.
- Excessive bleeding – Some degree of blood loss is tolerated by the patient. However, at times, excessive bleeding requires termination of the sinus surgery. Blood transfusion for sinus surgery is rarely necessary and is given only for urgent need.
- Spinal fluid leak – Since the sinuses are located near the brain, there is a rare possibility of creating spinal fluid leak or injuring the brain. If such complications arise, it would require surgical closure and hospitalization to avoid creating a potential pathway for infection, which could result in meningitis.
Why sinus surgery fails-post surgical factors
- Persistence of disease – Iatrogenic injury in the narrow space of the frontal recess with synechia formation can lead to recurrence or persistence of disease.
- Visual loss – In some cases, post sinus surgery, the visual loss has been due to eye injury or optic nerve. The recovery possibilities in such cases are not positive. Though such complications are rare, injury to the eye muscles may result in double vision. Persistent tearing of the eye is another possible complication that occasionally requires additional surgery if it is not resolved on its own.
- Recurrence of disease – Even though sinus surgery benefits the majority of patients, however, surgery is not always a permanent cure for sinusitis. Sinus medications even after successful sinus surgery might need to be continued. Sometimes additional touch-up or revision surgery may be necessary to optimize the surgical outcome.
Other uncommon post-surgery outcomes– uncommon risks of sinus surgery include alteration of the sense of smell/taste, persistence and/or worsening of sinus symptoms and facial pain, changes in voice quality, and swelling/bruising around the eyes.
The Bottom Line
There is a considerable impact of failed surgery, whether economic, emotional, or health-related.
Recognition and effective communication of such findings on reasons of failure for sinus surgery should lead to better patient care and may reduce the likelihood of additional surgical failures.
A holistic approach including meticulous medical management, comprehensive technique with mucosal preservation and minimal mucosal trauma, full removal of all diseased cells, and thorough postoperative care, can lead to enhanced outcomes and fewer technical failures.