How do I know if my patient needs
sinus surgery?
Too many patients are told they need surgery before other diagnoses have been considered and other treatment options have been exhausted, U-M doctors caution

Jeffrey Terrell, M.D., director of the Michigan Sinus Center and professor of otolaryngology, Melissa Pynnonen, M.D., associate professor of otolaryngology, and Mark A Zacharek, M.D., associate professor of otolaryngology

Determining when a patient's sinus problems warrant surgical intervention is more complicated than one might expect.

Nearly half of all Americans have allergies, nasal obstruction, colds or frequent headaches that can mimic the symptoms of true chronic sinusitis. And 30 to 40 percent of people without sinus symptoms, if given a CT scan, would have abnormalities consistent with sinus infection.

So, in a random collection of people on the street, roughly 1 in 6 would have symptoms and radiologic findings that might indicate they're a good candidate for sinus surgery when, in actuality, few of them would actually
benefit from it.

"The problem is a lack of specificity of 'sinus' complaints - headache, nasal drainage, stuffiness, post nasal drip - combined with a lack of specific findings on a sinus CT scan," says Jeffrey Terrell, M.D., director of the Michigan Sinus Center and professor of otolaryngology at the University of Michigan Medical School.

Melissa Pynnonen, M.D., associate professor of otolaryngology at U-M, adds, "I always tell my patients that a doctor can't just look at their CT scan and know whether they need sinus surgery. It requires a thorough workup."

That would include taking a detailed patient history, carefully reviewing CT films and conducting a physical examination, which might include nasal endoscopy, she notes.

"The most common diagnoses that masquerade as chronic sinusitis are allergic rhinitis, a deviated septum, gastroesophageal reflux disease, and migraine headaches or other headache syndromes," says Mark A Zacharek, M.D., associate professor of otolaryngology at U-M.

Here are five indications a patient is NOT likely to be a good candidate for sinus surgery:

1. The patient has recurrent sinus infections, but has never been evaluated or treated for nasal allergies or dental infections.
2. The patient's CT scan is normal when they are symptomatic. Patients with chronic sinusitis simply do not have normal CT scans when they are symptomatic.
3. The patient has severe headaches, but only minimal abnormality on their CT scan. Bad< headaches (7 or higher on a scale of 1-10) are more likely an indication of migraine.
4. The patient's CT scan shows abnormalities consistent with chronic sinusitis, but the patient doesn't have classic sinusitis symptoms - such as yellow-green discharge, nasal blockage and poor sense of smell.
5. The patient's CT scan shows a mucosal retention cyst, but the patient lacks symptoms of sinusitis and other CT-scan abnormalities. These cysts are common and usually have no clinical significance.

Here are five indications a patient IS likely to be a good candidate for sinus surgery:

1. The patient's sinus infections recur following a thorough medical workup, allergy evaluation, search for other underlying conditions and maximal medical therapy.
2. The patient has polyps obstructing the nasal passages that don't respond to steroid sprays.
3. The patient has evidence of fungal sinusitis, which is usually identified by CT findings and clinical history.
4. The patient has an impaired or suppressed immune system and recurrent sinus infections despite prior treatment.
5. A foreign body in the patient's sinuses keeps getting infected. Common objects include dental amalgam, surgical implants, and bone fragments from a prior surgery or facial trauma.

The Michigan Sinus Center, located in Livonia, specializes in the medical and surgical management of patients with chronic sinusitis and in all surgeries of the sinuses. The Center is staffed by the U-M Department of Otolaryngology, which was ranked No. 9 in the country by U.S. News & World Report in 2011.

FOR MORE INFORMATION
University of Michigan Sinus Center