Sinus Surgery

Patients who come to see me about sinus surgery, also known as functional endoscopic sinus surgery (FESS or ESS), are often dealing with a frustrating combination of blocked nose, facial pressure, postnasal drip, poor smell, repeated flare-ups, and treatments that have only partly helped. I have performed hundreds of endoscopic sinus operations for a wide range of sinus problems and disease severity. Endoscopic means the surgery is done using a fine camera passed through the nostrils, with no cuts on the outside of the nose or face. An important part of my role is helping each patient decide whether surgery is appropriate, how extensive it needs to be, and what still needs to happen afterwards to keep the disease under control.

For the right patient, endoscopic sinus surgery can make a very real difference. It can improve nasal airflow, reduce the burden of repeated infections and flare-ups, and make medical treatment work much more effectively. For others, the better option is continued medical treatment, further assessment, or dealing with another contributing issue first. The right decision is always made on an individual basis.

What are the sinuses, and why do they cause problems?

The sinuses are air-filled compartments within the bones around the nose. Each sinus has a natural opening that allows ventilation and drainage.

If those openings become blocked by swelling, inflammation, thick mucus, or polyps, the sinuses cannot function properly. Ventilation is impaired, drainage becomes poor, and symptoms such as blockage, pressure, discharge, postnasal drip, and reduced smell can develop.

The aim of sinus surgery is to re-establish those natural openings and restore function. How much needs to be opened depends on the pattern and severity of disease. In some patients only limited surgery is needed. In others, more extensive opening of the affected sinuses is required. If polyps are present, these are also removed where needed.

Why might sinus surgery be recommended?

Sinus surgery is usually considered when sinus disease is still causing significant symptoms despite appropriate medical treatment.

That might include:

• chronic sinusitis that is not settling with saline rinses and nasal steroid treatment

• recurrent acute sinus infections

• ongoing blockage from inflammation or nasal polyps

• persistent postnasal drip or discharge

• reduced sense of smell

• disease seen on endoscopy or CT scanning that fits with the symptoms

The main aim of surgery is not simply to remove sinusitis. The aim is to improve long-term control of the condition when medication alone has not been enough.

Do I need a CT scan before surgery?

In most patients, yes.

A CT scan of the sinuses is an important part of planning surgery. It shows the anatomy, the pattern and extent of disease, and how close the sinuses are to important surrounding structures such as the eye socket and skull base. It also helps determine how much surgery is needed and whether there are other factors, such as a deviated septum, that may need to be taken into account.

Depending on the pattern of symptoms, other tests may occasionally be needed as well. That might include further imaging, blood tests, allergy assessment, dental assessment, or other investigations where the wider picture suggests they would be useful.

What does the operation involve?

Endoscopic sinus surgery is usually performed under a general anaesthetic. A fine telescope and camera are passed into the nose through the nostrils, so the operation is performed internally without cuts on the outside of the face.

The exact extent of surgery depends on the pattern of disease. The aim is to widen the natural drainage pathways of the sinuses, remove obstructing inflammatory tissue where necessary, and improve access for long-term medication afterwards.

If nasal polyps are part of the problem, these are removed during the operation. In selected cases the surgery may also be combined with other procedures. A septoplasty may be needed if a significantly deviated septum is contributing to blockage or limiting access. A turbinoplasty may also sometimes be helpful if enlarged turbinates are part of the problem. In some cases I may also use image-guided navigation or balloon techniques where they are likely to add value.

What if nasal polyps are involved?

Nasal polyps are part of inflammatory sinus disease. Surgery can remove obstructing polyps and improve the nasal airway, but it does not switch off the underlying tendency to inflammation.

That point is important. If the underlying cause for the inflammation is still there — for example asthma, or a broader inflammatory tendency affecting the nose and sinuses — long-term medical treatment is still required after surgery.

In other words, surgery is often done to open the blocked sinuses so that medication can actually reach them properly. This is one of the main reasons surgery helps. It allows saline rinses and steroid treatment to get into areas that were previously obstructed. If medication is stopped completely afterwards, the inflammation and polyp disease will often return over time.

Will I still need medication afterwards?

Usually, yes.

The postoperative treatment plan varies from patient to patient, but most patients will need ongoing saline rinses and nasal steroid treatment after surgery. Some also need drops, antibiotics, short courses of steroid tablets, or other treatment depending on the type of sinus disease, whether polyps are present, and how the nose is healing.

Continuing the right medication after surgery is one of the key factors that helps the result last.

What happens immediately after surgery?

Most endoscopic sinus operations are done as a day case, although some patients stay overnight depending on the extent of surgery, the underlying disease, and how they are after the anaesthetic.

It is common for the nose to feel blocked for the first week or so after surgery. There is often some blood-stained discharge and congestion early on, and the nose usually feels worse before it starts to feel better.

I usually use dissolvable packing inside the nose at the end of surgery. This commonly softens and dissolves over time. Occasionally a different type of packing is used and needs to be removed later.

What are the benefits of surgery?

For the right patient, endoscopic sinus surgery can:

• improve nasal blockage

• reduce discharge and postnasal drip

• reduce the frequency and severity of flare-ups

• improve access for saline and steroid treatment

• help achieve better long-term control of chronic sinus disease

It is important to be realistic. Surgery often improves symptoms significantly, but it does not guarantee that every symptom will disappear, and it does not guarantee that smell will return fully. In particular, smell recovery can be unpredictable.

What are the main risks of endoscopic sinus surgery?

Endoscopic sinus surgery is a very common and usually safe operation, but like any procedure it has risks.

The commoner short-term issues include:

• bleeding or blood-stained discharge

• temporary blockage and crusting

• infection

• scar tissue forming inside the nose

• the need for ongoing postoperative cleaning and medication

Most bleeding is minor, but more significant nosebleeds can happen and occasionally require further treatment. Healing surfaces inside the nose can also stick together and sometimes need to be divided later.

There are also rarer but more serious risks. Because the sinuses sit very close to the eye socket and skull base, uncommon complications can include bruising around the eye, watery eye, double vision, bleeding into the eye socket, leakage of fluid from around the brain, meningitis, and extremely rarely loss of vision.

As with any operation under general anaesthetic, there are also the usual anaesthetic risks, which depend partly on the individual patient and their general health.

What is recovery like?

Good aftercare makes a real difference to recovery.

Nasal douching instructions

Nasal douching is one of the most important parts of postoperative care. It helps wash away blood, mucus, and crusting, and supports healing.

A simple saline douche can be made using:

• 1 flat teaspoon of salt

• 1 flat teaspoon of bicarbonate of soda

• approximately 1 pint of cooled boiled water

Many patients prefer a bottle-based rinse such as NeilMed because it gives a more thorough wash. Some use a saline spray instead, particularly early on if the nose feels very sensitive.

Activity

I usually advise patients to take it easy for the first few days after surgery. Heavy lifting, strenuous exercise, gym work, bending, and anything likely to provoke bleeding should then be avoided for 6 weeks, as this helps reduce the risk of postoperative bleeding.

Time off work

This depends on the extent of surgery and the type of work you do, but many patients need around 1 to 2 weeks off work. If your job is physically demanding, involves heavy lifting, or takes place in a dusty environment, you may need longer.

Nose blowing

Do not blow the nose for the first couple of days, then start very gently. Minor blood-stained mucus is common early on.

Follow-up

Follow-up matters. Depending on the extent of surgery and the type of disease, I may need to see you to assess healing, clean the nose if needed, and adjust the postoperative medication plan.

When should I seek urgent help?

Urgent advice is needed if there is:

• heavy or persistent fresh bleeding

• worsening swelling around the eye

• double vision or change in vision

• severe worsening headache

• fever with significant deterioration

• severe pain not settling with medication

• any concern that recovery is going off course

Useful links

• ENT UK – Sinus surgery for chronic rhinosinusitis without nasal polyps

• ENT UK – Sinus surgery for chronic rhinosinusitis with nasal polyps

• Oxford University Hospitals – Nasal douching instructions

Disclaimer

This page is intended as general information only. It does not replace a consultation, examination, or individual medical advice.