Before about 1991, sinus surgery using a small camera (endoscopic sinus surgery) basically didn't exist. Between about 1991 and 1994, the field was changing fast and very few surgeons had much experience with the tools and techniques we now take for granted. The only sinuses that were usually operated on back then were the cheek sinuses (maxillary sinuses). Problems in the sinuses between the eyes (ethmoid), in the forehead (frontal), and deep behind the nose (sphenoid) were very hard to treat and even hard to diagnose. 

The usual older operation was to straighten the nasal wall (septoplasty) if needed, make small drainage openings into the cheek sinus, and sometimes shrink or remove part of the lower scroll-shaped structure inside the nose (the inferior turbinate) — sometimes too much. If these patients also had disease in the ethmoid, frontal, or sphenoid sinuses, they usually only got partial relief. This is very common. Before camera techniques came along, getting into these other sinuses was dangerous and often needed cuts on the face that left scars. It's understandable that these commonly affected areas were left alone. 

Solution - Today, almost all patients have a CT scan first to find every problem area. In experienced hands, all of these areas can be safely treated with fairly minor procedures.

This isn't quite what it sounds like — let me explain. A common failure I see is the patient who came in complaining of congestion and trouble breathing, maybe even sinus pain. The doctor looks in the patient's nose and finds a clearly crooked nasal wall (deviated septum). He thinks, wow, that crooked septum really needs to be fixed — and he's right. The missed opportunity is not checking for other problems that can exist along with a crooked septum. Long-lasting sinus inflammation (chronic sinusitis) is very common, and probably more common in people with very crooked septums.

So the doctor fixed the crooked septum, the patient may breathe a little better, but the problems aren't fully solved. It turns out this patient also had long-lasting sinus inflammation that was part of the picture, but perhaps without the usual symptoms. If the doctor had done a CT scan before surgery, those hidden problems would have shown up. In fact, in this patient, the long-lasting sinus inflammation might have cleared with the right medicines and avoided surgery altogether. That's the worst-case situation: having a procedure that doesn't help for a problem that could have cleared with medicine.

Solution - This can be avoided by getting a CT scan before surgery in patients having almost any kind of nasal surgery. Even when the scan shows no long-lasting sinusitis, it helps me plan the septoplasty and any shrinking of the inside of the nose (turbinate reduction). I'm amazed how often I find unexpected long-lasting sinusitis, an air pocket inside a turbinate (concha bullosa), or other findings in a patient I expected only needed a septoplasty. Compared to all the other expenses of surgery, a CT scan — usually covered by insurance — is money very well spent in many cases.

This happens to every sinus doctor from time to time. A common situation: a patient has the story of long-lasting sinus inflammation (chronic sinusitis). A long course of antibiotics is given, then a CT scan at the end shows certain sinuses that haven't cleared. A minor procedure opens those stubborn sinuses, and the other sinuses are left alone, as they should be. After surgery, things are better, but the patient gets infections that are once again hard to clear. Eventually another CT scan is done and shows that some of the sinuses that were not operated on are the ones now causing the trouble.

This is not uncommon. The basic idea of modern sinus surgery is that we should not disturb things that aren't causing a problem. That sounds reasonable, but knowing for sure whether opening a sinus will help isn't always easy. In the patient above, the CT was assumed to show the source of infection. Later it became clear they actually had problems in several areas, but some had quieted down by the time of the CT scan.

There isn't much we can do to fully avoid this. I usually do a careful look at the areas I am not planning to operate on, both with the camera and on the CT scan, just to be sure they look good. Another option would be to get the CT scan during a flare-up, but then you might end up operating on areas that could have cleared with medicine.

Solution - There is no perfect solution. We can keep these patients to a minimum by using good judgment and by asking the patient whether they would prefer a bit more or a bit less surgery, knowing each option has trade-offs. Doing a little more lowers the chance that a normal-looking sinus will become blocked later, and lowers the chance of needing a second "tune-up" operation. The downside is more surgery, possibly on areas that would have been fine, and a slightly higher chance of bleeding or healing problems.

When a patient needs a second operation, I think it's wise to change the plan. The goal of a first (hopefully only) sinus operation is to do the least work that will likely fix the problem — this serves most people very well. The goal of a second operation is to be pretty sure there won't be a third one. With that in mind, I usually open any sinus that's a possible suspect, where it's safe and simple to do so. This varies with the patient's history and anatomy.

Some people with long-lasting sinus inflammation (chronic sinusitis) have a condition called allergic fungal sinusitis (AFS). This is one group that often isn't "cured" by sinus surgery. AFS is a reaction some people have to mold spores in the air. It's not really an allergy. People with AFS usually have growths in the nose lining (nasal polyps) and a thick material filling one or more sinuses. Some debated theories suggest that many people without obvious polyps or fungal material may have a milder version of the same reaction. 

People with AFS are more likely to grow polyps back and have ongoing swelling, even when all the problem sinuses are open and well treated. Surgery is still very helpful and is one of the only ways to get relief, but in some people the disease keeps going despite surgery and medicines.

Solution - For some people there is no easy fix. Surgery almost always reduces symptoms and makes flare-ups easier to treat. Steroid pills like prednisone help dramatically, but they have side effects that make them unsuitable for frequent or long-term use. 

Rinsing the nose with anti-fungal medicine has been shown to lower flare-ups. These rinses don't usually work unless the sinuses have already been opened with surgery.

Careful follow-up, well-timed steroid use, and anti-fungal nose rinses can help reduce flare-ups in people with AFS.

Some people with AFS will need occasional polyp removal or, sometimes, a more involved repeat operation to keep the disease under control. 

Some polyps come from causes we don't fully understand. Sometimes they can be removed and never come back. Other times, no matter what is done, they return. In people with polyps, it may be necessary to go back in and clean out any new growth to keep things draining and to keep the airway open.

Solution - When more surgery becomes needed, the return trips to the operating room can often be spaced many years apart, and they are usually minor procedures. Steroid injections, new implants placed into developing polyps, and steroid sprays can slow or reverse their growth. Steroid pills are very helpful, but not everyone can take them, and they can have side effects. The goal is to keep things reasonably open and comfortable, and to space out any future polyp surgeries as far as possible. 

Sometimes the perfect operation is done on the perfect patient and things just don't heal the way we want. Certain healing problems after surgery are well known. People sometimes call this "scar tissue" forming. What is actually happening is that the lining of the nose (mucous membranes) heals over a spot we wanted to stay open, or heals two nearby structures together.

Poor healing is most likely in people who had active swelling at the time of surgery or after it. Some conditions are more inflamed than others, and this is fairly easy to judge during the operation. Poor healing also tends to happen more easily in people with a very narrow nose inside. 

Solution - I think a lot of poor healing happens when blood from the surgery hardens in the cavities and acts like a "bridge" for the lining to grow across. In the weeks after surgery, it really helps to bring the patient in for a look, and if there is dried blood left in there, it gets cleaned out. Cleaning the cavities after surgery, when needed, is a critical step in some cases.

The middle scroll-shaped structure inside the nose (the middle turbinate) drifting outward and healing to the side wall is a common example of a site not healing the way we want. Sometimes it helps to remove part of the middle turbinate ahead of time to prevent this if it looks likely. I often place a dissolving stitch to try to prevent it. Sometimes this needs to be handled at the post-op visits if it happens unexpectedly.

In my opinion, this is the toughest situation. Out of the many patients I see each year, about 1 or 2 will have this problem. It usually happens in people who have had a long-standing bacterial infection in the cheek sinuses (maxillary sinuses) or who have some kind of immune problem like diabetes.

In these patients, the sinuses may heal as expected after surgery, but puddles of what looks like infection stay in the bottom of the cheek sinuses. Cultures are taken, but for some reason they often don't show the bacteria causing the problem. Maybe bacteria aren't really the cause, but it looks like they are. So multiple antibiotics are tried based on educated guessing, but the puddles stay. The most common symptoms are post-nasal drip and cough.  Sometimes bacteria like staph or pseudomonas are found.  These can cause crusting and can be very hard to get rid of.

Solution - This is a hard problem, but usually a fix can be found. In my practice, the next steps include: repeating cultures, because sometimes a guilty bacteria can be identified and treated with an unexpected antibiotic; frequent return visits to put strong antibiotics directly into the sinus and clean it out. (We never actually do this, but I think that if these patients were put to sleep every day for a couple of weeks and had their sinus aggressively rinsed out with antibiotics placed inside, they would clear up. That isn't practical, but visits 2 or 3 times a week for rinsing and antibiotics can sometimes be arranged.) Using antibiotic rinses at home is another option. We can also consider placing a "window" at the bottom of the sinus. That lets material drain out by gravity and lets antibiotic or saltwater rinses reach the inside of the sinus more fully. Eventually one can "saucerize" the sinus, which almost always cuts down the amount of infection and helps get it under control. The downside is that it changes the natural anatomy a fair bit, and many people get relief without taking that step.