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Nose

Allergy


Allergy is an inflammatory response produced by the body’s immune system to foreign substances that enter the body. Allergens are allergy producing substances such as pollens, dust mites, molds, animal dander, foods, insect stings, and certain medicines. Allergies can occur at any age and are very common in people who have a family history of allergies.

The most common allergic disorders include:

  • Allergic rhinitis (hay fever) is an inflammatory disease of the nasal lining. It is caused by allergens such as dust mites, animal dander, or molds. You may develop symptoms such as sneezing, nasal congestion, itchy nose and eyes, running nose, and sore throat. The risk factors for developing allergic rhinitis include smoking, pollution, infection, and hormonal imbalance.
  • Asthma is a chronic disease of the lower airway that causes inflammation and narrowing of the air passages resulting in wheezing, shortness of breath, coughing, and chest tightness.
  • Allergic conjunctivitis is inflammation of the membranes covering the surface of eyeball and eyelid. The inflammation causes redness of the eye, watery or itchy eyes and swelling of the membranes.
  • Allergic eczema or allergic dermatitis is an allergic rash, commonly associated with allergic rhinitis or asthma resulting in rashes around the eyes and face.
  • Allergic shock or anaphylaxis is a severe reaction which is life-threatening, affecting different areas of the body. The condition is often caused by substances that are injected or foods, and results in skin discoloration, nasal congestion, and shortness of breath, wheezing, and swelling of the throat.

Consult your doctor or an allergist to seek treatment option. Your allergist will first obtain a detailed medical history and examine you before the treatment is started. Skin tests and other allergic tests will be required to identify the exact cause of allergy.

Following the tests the treatment will be started which includes:

  • Prevention: Prevention or avoidance is the best treatment for allergies. If the cause of the allergy is identified it should be eliminated or avoided. For example if you are allergic to some food or animal fur it should be removed or kept away. If you are allergic to tobacco smoke, avoid smoking to prevent allergy.
  • Medications: Short term decongestant sprays, steroid nasal sprays, and antihistamines may be used to relieve symptoms.
  • Immunotherapy: If a specific allergen is detected, injected allergens titrated from tiny doses to larger doses over a long period can be very effective. Newer immunotherapy can also administer the allergen under the tongue to avoid injections.

Tips to prevent allergies

  • Avoid exposure to allergens that trigger allergy at home such as pets, mold, and dust mites
  • Wash bed sheets and pillow covers with warm water and use allergy resistant pillow covers
  • Avoid smoking and use of tobacco

Nasal Obstruction

Coming soon

Chronic sinusitis

Nasal sinuses are hollow, air containing cavities in the skull behind the forehead and cheeks of the face. There are four pairs of sinuses and these are referred to as the paranasal sinuses. Sinusitis occurs when one or more sinuses become infected, causing inflammation of the membranes that line the sinus cavity. Nasal polyps, grape-like growths of the sinus membranes that protrude into the sinuses or into the nasal passages, may form, making it even more difficult for the sinuses to drain and for air to pass through the nose. Sinusitis is a common problem affecting millions of people around the world.

Symptoms

One of the most common symptoms of sinusitis is pain, and the location depends on which sinus is affected. Most people with sinusitis have pain or tenderness in several locations, and their symptoms usually do not clearly indicate which sinuses are inflamed. Chronic sinusitis is also strongly associated with nasal symptoms such as a stuffy nose, thick nasal secretions that are yellow, green or blood-tinged, as well as a general feeling of fullness over the entire face. Less common symptoms of sinusitis can include:

  • Tiredness
  • Decreased sense of smell
  • Cough that may be more severe at night
  • Sore throat
  • Bad breath
  • Fever

On rare occasions, acute sinusitis can result in brain infection and other serious complications if left untreated.

Causes

The causes of chronic sinusitis are largely unknown. The condition often occurs in people with asthma, the majority of who have allergies. However, at least half of all people with chronic sinusitis do not have allergies. Other causes of chronic sinusitis may be an immune deficiency disorder (HIV infection) or an abnormality in the quality of mucus produced by the respiratory system (cystic fibrosis). Another group of people who may develop chronic sinusitis are those with significant anatomic (structure) variations inside the nose, such as a deviated septum, that lead to blockage of mucus.

Treatment

The non-surgical treatment for sinusitis is the administration of nasal steroid sprays and oral antibiotics, alone or in combination. Many doctors also recommend using saline (saltwater) washes or sprays in the nose to help remove the thick secretions and allow the sinuses to drain. When medicine fails, surgery may be the only alternative for treating chronic sinusitis. The goal of surgery is to improve sinus drainage and reduce the blockage of the nasal passages. During surgery, the surgeon enlarges the natural opening of the sinuses, and removes polyps and corrects anatomic deformities that contribute to the obstruction.

Nose Bleeds

Coming Soon

Blocked Nose

Nasal congestion occurs when the tissues lining the nose become swollen, or there is an underlining anatomic abnormality.

The four main causes of blocked nose are:

  • Infections: Common cold, flu, and sinus infections are commonly caused by viral infection. This can be complicated by bacterial infection.
  • Structural abnormalities: These include deformities of the nose and nasal septum such as deviated nasal septum (cartilage that divides the two nostrils), large inferior turbinates, polyps in the nose, external valve collapse, bent or twisted nose, and large adenoids.
  • Allergies – Allergy occurs due to the inflammatory response to harmless environmental substances known as allergens such as pollen, dust mites, house dust, and animal dander, tobacco smoke. These allergens cause release of a substance called histamine which promotes an inflammatory response in the nose leading to congestion and excess production of watery nasal mucous.
  • Vasomotor rhinitis –Is a non-allergic condition that causes inflammation of the nose and nasal membranes because of abnormal nerve control of the blood vessels in the nose. Membranes of the nose have the ability to expand and contract. During the allergic response these membranes expand leading to nasal congestion. Some of the factors that expand these membranes are irritants such as perfume, tobacco smoke, and psychological stress.

Surgery may be needed to correct the anatomic abnormalities. Some of the surgical procedures include

  • Septoplasty– To correct the deviated nasal septum
  • Turbinoplasty– For the reduction of large inferior turbinates
  • Polypectomy– To remove the nasal polyps
  • Functional rhinoplasty – For external valve collapse. Rhinoplasty surgery is done for bent or twisted nose
  • Adenoidectomy – To remove enlarged adenoids
  • Endoscopic sinus surgery – To open the obstructed sinuses

Broken Nose

Common symptoms of broken nose include pain, swelling and bruising around the nose or eyes, bleeding, crooked or misshapen nose, crackling sound or feeling on touching the nose, blocked nasal passages, and difficulty in breathing.

Complications

Possible complications of a broken nose include deviated nasal septum, nasal septal hematoma (collection of blood), cartilage fracture, cervical spine or neck injuries, cerebral spinal fluid draining from the nose (CSF rhinorrhoea), loss of sense of smell, infection, and difficulty in breathing.

Treatment

In case of minor fracture your doctor recommends to follow self-care measures such as applying ice on the affected area, keeping the head elevated, and taking medicines such as acetaminophen (Tylenol) to reduce pain.

If there is continuous bleeding, moisture nasal gauze strips with antibiotic ointment may be packed over the nose which will prevent infection. And if there is a blood clot (hematoma), then your doctor will drain the blood clot by making small incision.

If the bone is displaced, a closed reduction is performed. This is usually done within 7 to 14 days of breaking the nose.

If closed reduction is not performed in a timely fashion, or is not successful, then surgery can be performed to realign and reshape the nose (rhinoplasty). If the break has damaged the nasal septum causing difficulty in breathing, then septorhinoplasty is performed to reconstruct the nose.

Nasal Polyps

Nasal polyps are sac-like outpouchings from the nasal lining caused by inflammation of the mucous membranes. It may be the end result of chronic diseases such as chronic sinusitis, and aspirin sensitivity.

Patients with nasal polyps often develop symptoms of a cold that will last for several months. Other symptoms include, breathing through mouth, blocked nose, running nose, and loss or decreased sense of smell and taste.

Your ENT doctor will perform nasal endoscopy by placing a small camera into the nose for a better view of the nasal passages to confirm polyps. A CT scan may also be beneficial.

Treatment for nasal polyps includes medications such as nasal steroid sprays, corticosteroids, antileukotriene medications, nasal saline, and possible immunotherapy. Surgery may also be recommended by your doctor in severe cases to remove the nasal polyps. The most commonly suggested procedure is ‘endoscopic sinus surgery’ (ESS). It is performed using an endoscope which helps to view nasal cavities better and may also be combined with medical therapies to prevent recurrence. Removal of polyps by surgery makes it easier to breathe through nose.

Snoring

Snoring is the sound produced by vibrations of tissues of the nose and throat on breathing during sleep. Snoring is more common in men than women, and may increase with advancing age.

Normally when we breathe, air flows in and out from nose or mouth to lungs, in a steady flow, but during sleep, the area at the back of the throat, nose or mouth may get narrowed and when the air passes through this narrow opening, the surrounding tissues vibrate, producing sounds of snoring.

The most common cause of snoring is nasal passage obstruction caused from nasal septum deviation, allergies, sinus infections, swollen turbinates (nasal concha) and enlarged tonsils. It may also be seen in children who breathe through their mouth.

Certain medications and alcohol increase the relaxation of the muscles of the palate, tongue, neck, and pharynx, leading to a smaller airway and greater tissue vibration, resulting in snoring. Snoring can also be a sign of sleep disorders or other sleep-related breathing problems.

Your doctor evaluates snoring by taking a completed medical history and by physical examination. You may be asked about your snoring and sleep pattern and sleep problems. Body mass index (BMI) and neck circumference are estimated. Your physician may examine your throat, nasal and oral cavities to determine narrow oral and nasal passages. If sleeping problems are suspected, then a sleep study can be performed.

Treatment options for snoring include non-surgical and surgical treatment.

Non-surgical treatment:

  • Behavioral changes: This therapy includes losing weight if overweight, avoiding alcohol or sedative medications, stop smoking, and changing sleeping positions.
  • Dental devices: Dental devices hold the jaw forward, and may be used for mild snoring and in people who have not responded from behavioral changes.
  • Nasal devices and medications: Adhesive nasal strips are available, which can be placed over the nose. These will help in widening the nostrils and makes breathing easy. Nasal steroid sprays may be used to decrease the inflammation in the nasal passages. Decongestants nasal sprays and drops are prescribed to relieve the stuffy nose. These medicines shrink the swollen blood vessels in the lining of the nose and help to improve snoring resulting from nasal congestion.
  • Nasal continuous positive airway pressure: Nasal continuous positive airway pressure (CPAP) is a device that prevents narrowing of the airway during inspiration and expiration by providing a persistent increased pressure.

Surgical treatment: The goal of the nasal surgery is to improve the narrow nasal passage. Surgery may be needed to correct the anatomic abnormalities. Deviated nasal septum may be surgically corrected with a septoplasty procedure. Polypectomy is done to remove the nasal polyps.

Sleep Medicine and Surgery


Sleep is essential for your physical health and emotional wellbeing. Everyone experiences occasional sleeping problems, but if you experience problems sleeping repeatedly, it could indicate an underlying health problem. Sleep disorders are problems associated with sleeping, including difficulty falling or staying asleep through the night, feeling sleepy during the day, or waking up feeling exhausted. Because of lack of sleep you may find it difficult to concentrate and perform activities of daily living. This lack of sleep can lead to depression, mood swings, or other health problems.

Some of the common types of sleep disorders include:

  • Insomnia:  Insomnia is a type of sleep disorder in which the person has difficulty falling asleep or staying a sleep.
  • Sleep apnea: Sleep apnea is a common sleep disorder in which breathing stops or gets very shallow during sleep. These breathing pauses last between 10 to 20 seconds or more.
  • Restless leg syndrome (RLS): Restless leg syndrome is a disorder characterized by a tingling or prickly sensation in the legs and an urge or need to move the legs.
  • Narcolepsy: Narcolepsy is a sleep disorder that causes excessive daytime drowsiness and sudden onset of sleep.
  • Parasomnias: This refers to abnormal behaviors that occur during sleep. Parasomnias include nightmares, night terrors, sleep walking, and sleep talking, head banging, wetting the bed and grinding teeth.

Sleep studies

Sleep disorders can be detected through sleep studies, which are tests that evaluate how well you sleep and your body’s response to sleep problems. The following are a few sleep studies:

  • Polysomnogram (PSG): During this test, sensors are placed on your body to record eye movement, heart rate and rhythm, blood pressure, brain activity and the amount of oxygen in blood. Elastic belts are strapped around your stomach and chest to measure chest movements, and the duration and strength of inhalation and exhalation. These measures are simulated by a computer to detect any abnormalities in your sleeping pattern.
  • Multiple sleep latency test (MSLT): MSLT is a daytime test, which usually follows a PSG test. Similar to the PSG test, sensors are placed on your body to record eye movement and brain activity. It indicates how long it takes for you to fall asleep and the different stages of sleep. The test is repeated four to five times across the day with intermittent waking.
  • Maintenance of wakefulness test (MWT): This test is performed the day after PSG.

Treatment

Sleep Disorder treatment can be classified into two main categories: pharmacological treatment and non-pharmacological treatment.

Pharmacological treatment includes any prescription or non-prescription medications to help prevent the onset of the symptoms or treat the developed symptoms. Depending on the type of disorder, treatment could include sedatives (in case the condition is related to insomnia), or stimulants (in case the condition is related to narcolepsy or sleep apnea).

Non-pharmacological sleep treatment refers to those options that do not require the use of prescription or non-prescription drugs. These may include behavioral therapy, medical equipment, surgery, and other options. Surgery may be needed to correct the anatomic abnormalities of the upper airway which can lead to the onset of obstructive sleep apnea. Behavioral treatments for sleep problems may include relaxation training, cognitive therapy, stimulus control (SC), sleep restriction therapy (SRT), and sleep hygiene. Behavioral therapy can be usedtotreatpeople with insomnia, parasomnias, bedwetting, and other sleep problems. Another option is the use of different types of medical equipment such as “continuous positive airway pressure” (CPAP) and bilevel — or BiPAP for the treatment of sleep apnea. CPAP is a device that prevents narrowing of the airway during inspiration and expiration by providing a persistent increased pressure. Another similar option is “bilevel” in which the face mask allows for two different alternating pressures: one with inhalation and one with exhalation. Other non-pharmacological treatment options for sleep disorders include mandibular advancement devices, nasal strips, positional therapy, and playing didgeridoo (a wind instrument) to strengthen the upper airway.

Lifestyle changes, such as beginning a regular exercise program, establishing regular sleep patterns, and eliminating or decreasing the use of caffeine, alcohol, and tobacco, may also be helpful.

Newborn Breathing/Complex Airway Care

In infants, the airways and nasal passages are very small and narrow and are filled with amniotic fluid and mucous. Your baby will take some time to clear the amniotic fluid and mucous and makes adjustments to breathe on its own. During this process they may cough, produce noises, and also develop breathing difficulties. The normal breathing in children is affected by posture, sleep state, and gestational age.

Causes

Some of the causes of breathing problems in children can be related to the heart, the lungs or the airway.

Airway obstruction can be due to blockage of the nose, throat, voicebox (larynx), windpipe (trachea) and lower airway (bronchi).

Enlarged tonsils and adenoids are a frequent cause of airway obstruction in children, particularly in sleep, and can lead to obstructive sleep apnoea (OSA). Adenotonsillectomy is the most common treatment and is successful in the majority of cases.

Immaturity of the larynx (laryngomalacia) is also very common and may present with a high pitched noise heard on breathing in (inspiration), poor feeding, and failure to thrive. Most children will grow out of this problem with age. More severe cases may require surgery.Surgical treatment usually involves supraglottoplasty (operation on the tissue above the voicebox).

Foreign body inhalation is also a common problem in children. This can result in death. Children under 2 should not be given uncooked apple or carrot, hard lollies, or peanuts or nuts of any kind. These are the most commonly inhaled foreign bodies. Children should always be seated when eating. Foreign body aspiration frequently occurs when children are running or walking whilst eating. Surgical bronchoscopy may be required to remove the foreign body from the lower airway.

Inferior turbinate reduction is a surgery carried out to reduce the size of the turbinates inside the nose without impairing their natural function.

Turbinates are the bony and soft tissue projections inside the nasal passageways on each side of your nose. The turbinates function as natural air filters trapping irritants (dust, pollen, etc) from the air you breathe. They are also responsible for warming and humidifying the inhaled air. The nasal passageways have 3 pairs of turbinates: inferior, middle and superior. Out of the 3, the inferior turbinate is the lowest and is the first to come in contact with the inhaled air.

In some people, the turbinates enlarge leading to narrowing of the nasal cavity. As a result, the free flow of air is obstructed causing symptoms of congestion and strained breathing. If this becomes a persistent long-term problem, your doctor may recommend surgery. It is the inferior turbinate that is usually addressed with the surgery.

Goals

  • Gentle reduction in turbinate size
  • Improvement in nasal breathing by eliminating obstruction in the nasal airway

Procedure

Inferior turbinate reduction is performed on an outpatient basis under local or general anesthesia. During this procedure, the surgeon makes a tiny incision in the lining of the turbinate to remove the underlying bone using specialized instruments. An endoscope (thin tube with a light at the end) is used to obtain the best possible visualization during surgery. Finally, any excess swollen tissue surrounding the turbinate is trimmed.

Risks and complications

Possible risks and complications associated with inferior turbinate reduction include crusting around the nostrils, bleeding, scarring and dryness. Your doctor may prescribe saline solution to relieve dryness and promote faster healing.

Post-Operative care

Your surgeon may recommend a few specific post-operative instructions for a speedy and successful recovery. This may include using nasal saline sprays every 2-3 hours to overcome nose dryness and associated problems. Avoiding heavy lifting, straining, nose blowing, and NSAID’s and steroid sprays for at least 2 weeks following the surgery is also recommended. Your surgeon will provide specific instructions upon discharge for you to follow.

Adenoidectomy is a surgery for removal of the adenoids. Adenoids are small lumps of tissue located behind the nose, just above the tonsils. However, they are not as directly visible as the tonsils. The adenoids are crucial in fighting off infections in babies and young children. They disappear as a part of the normal growing process, and are not seen in adults.

An adenoidectomy is undertaken in children with enlarged or infected adenoids, who frequently complain of breathing difficulties, chronic infections or earaches.

Procedure

An adenoidectomy is performed on an outpatient basis under general anesthesia. During this surgery, the patient’s mouth is kept open using a special instrument. After locating the adenoids, the surgeon removes the adenoids by either scraping or cauterization. Finally, the area is packed with absorbent material to control bleeding.

Risks and complications

Adenoidectomy is a fairly straight-forward surgery. However, as with any surgical procedure, there is a small chance of complications. Some of the potential complications include bleeding, bacterial infection at the surgery site, sore throat, blocked nose, and change in the voice, i.e., the voice sounds more “nasal”.

Nasal polyps are benign (non-cancerous) growths that develop in the lining of the nasal passages or sinuses. They are either present singly or as multiples, appearing as grey or yellow colored masses resembling a cluster of grapes.

Causes

The probable causes include a hereditary tendency to develop polyps or chronic inflammation of the mucosal lining of the nose. Researchers are yet to discover the exact cause of this inflammation trigger.

Symptoms

Patients with a polyp present in the nose often experience a decreased sense of smell associated with a stuffy, runny nose and asthmatic symptoms.

Procedure

Endoscopic sinus surgery is usually recommended for large sized polyps that do not respond well to medical treatment. The surgery is performed on an outpatient basis using an endoscope, a thin, flexible tube with a tiny camera on the end. The surgeon inserts the endoscope into your nostril and guides it into the sinus cavities. The endoscope camera helps in the clear visualization of the polyps. The polyps are then removed using tiny surgical instruments contained within the scope. Your surgeon may send some of the polyp tissue for pathological examination to rule out cancer. Your surgeon may also widen the openings of the sinus cavities during this surgery.

Occasionally, small, isolated polyps can be a source of discomfort. These can be surgically removed using a small suction device in an outpatient surgery called a polypectomy.

Risks and complications

The surgery is not entirely fool proof, and polyps may recur. Some of the potential complications include bleeding, leakage of spinal fluid due to the proximity of the brain and sinuses and very rarely, visual problems have also been reported.

Nasal cautery is a minor surgical procedure to treat recurring nose bleeds. Nose bleeds occur when the mucosa of the nose erodes, exposing blood vessels that break down causing bleeding. The mucosa may erode due to trauma, infections, or hypertension.

Nasal cautery is an effective treatment for persistent nasal bleeding caused due to damaged blood vessels in the front part of the nose. The goal of cauterization is to seal the ruptured blood vessels using heat or electricity to stop bleeding.

Procedure

Cauterization is a short duration surgical procedure usually done on an outpatient basis usually under local anesthesia. During this surgery, the exact bleeding location in the nose is confirmed by the surgeon. This is followed by the application of a local anesthetic agent. The surgeon may either pass electricity or apply a chemical such as silver nitrate to the bleeding vessel and the adjoining tissues by using an instrument. This leads to the formation of scar tissue in the area, which prevents further nosebleeds.

Risks and complications

Nose cauterization is a relatively risk-free surgery. However, as with all surgical procedures, there are potential risk factors involved in this surgery as well. One such factor is that the surgery can be performed only if the exact bleeding location has been identified. Also, the chemical silver nitrate can cause pain, in spite of application of a local anesthetic. Rarely, bleeding may be observed in the cauterized area.

Septoplasty is a reconstructive surgery performed to straighten a deviated nasal septum.

The septum acts as a dividing wall between the two nostrils. Deviations in the septum may develop as a part of the normal growth process during childhood and puberty. The deviation can also be present at birth or can be caused from injury to the nose.

Patients with a deviated septum often complain about breathing difficulties and repeated sinus infections.

Procedure

Septoplasty surgery is performed on an outpatient basis under general or local anesthesia. The surgery involves removing or readjusting deviated portions of the septum for improved breathing. During this surgery, the surgeon makes an incision on the inside of either nostril. This is followed by separation of the mucosal lining of the septum from the underlying cartilage. The surgeon then proceeds to straighten the deviation, taking care to remove any excess bone or cartilage and finally, replaces the mucosa over the cartilage and bone. The incision is closed with absorbable stitches.

Risks and complications

As with all surgical procedures, there are some potential risks associated with septoplasty.

There may be some bleeding in the first few days following surgery. The nose, eyelids, and upper lip might appear bruised and swollen. You may also experience numbness in the facial region. All these issues should resolve in a few days, except for the numbness at the tip of the nose. It may take several months to recover feeling at the extremity of the nose.

Balloon Sinuplasty


Sinuses are hollow air filled spaces in the skull, found between the eyes (ethmoid sinus), the forehead (frontal sinus), nose (sphenoid sinus) and cheek bones (maxillary sinus). The sinuses are lined with mucus secreting cells. This mucus traps the germs and the pollutants in the sinuses and is drained, through the opening of the sinus, into the nasal cavity. This keeps the sinuses clean and healthy.

Sinusitis refers to the inflammation of the mucus lining of the sinus and is often preceded by a cold or allergic attack. Inflammation of the sinus lining causes them to swell which blocks the passage preventing normal mucus drainage. The mucus now accumulates in the sinus, increasing the pressure within the sinus and also leads to recurrent sinus infections. The symptoms of sinusitis include pain, tenderness and swelling around the eye, cheeks, nose or forehead and nasal congestion with thick, yellow or green mucus discharge and reduced sense of smell and taste. Other symptoms may include ear pain, bad breath, fatigue, nausea, teeth pain, sore throat and cough. In majority of the cases sinusitis is acute; symptoms lasting beyond 3 months cause chronic sinusitis which impacts the quality of life of the patient.

Click here to read more about Balloon Sinuplasty.

Nasal sinuses are hollow, air containing cavities in the skull behind the forehead and cheeks of the face. There are four pairs of sinuses and these are referred to as the paranasal sinuses. Sinusitis occurs when one or more sinuses become infected causing inflammation of the membranes that line the sinus cavity. Sinusitis is a common problem affecting millions of people around the world.

Chronic sinusitis are cases which last more than 12 weeks and can continue for months or even years. Functional Endoscopic Sinus Surgery or FESS is minimally invasive corrective surgery for chronic sinusitis. Computer assisted endoscopic sinus surgery, also referred to as image-guided surgery (IGS), may be used to perform your sinus surgery.

Indications

When medicine fails, surgery may be the only alternative for treating chronic sinusitis. The goal of surgery is to improve sinus drainage and reduce blockage of the nasal passages.

Procedure

The surgery is usually done through the nose, the surgeon:

  • Enlarges the natural opening of the sinuses
  • Removes any polyps
  • Corrects significant anatomic deformities that contribute to the obstruction

Functional Endoscopic Sinus Surgery (FESS) is performed through the nose using an endoscope, a long, thin, tube which has a light and a video camera on the end. Images from the endoscope are magnified and projected on a TV screen enabling your surgeon to visualize internal structures in great detail.

FESS is performed under sterile conditions in the operating room with the patient under general anesthesia or local anesthesia with sedation. This operation is usually performed as outpatient surgery enabling the patient to go home the same day.

Depending on your particular situation, your surgeon may perform additional procedures to offer you the best possible outcome for your situation.

These may include the following:

  • Septoplasty: This is corrective surgery for a deviated nasal septum. The septum is the bony cartilage which divides the nose into two chambers. A deviated septum can interfere with breathing and predispose to sinus infections.
  • Ethmoidectomy: This is surgery to remove diseased tissue and bony partitions in the ethmoid sinuses.
  • Inferior Turbinoplasty: This surgery involves revision to the inferior choncha or turbinate bone. The turbinates are responsible for warming, humidifying, and filtering inspired air and can cause blockage of the nasal passages

Image guided surgery systems (IGS) enables the surgeon to perform a more thorough and precise surgery and has significantly improved the safety and effectiveness of the procedure.

In computer assisted surgery, special instruments are used that are connected to a computer system where they are tracked according to the patients’ anatomy based on pre-operative CT scans. Using tiny bone cutting instruments and debriders, your surgeon will enlarge the sinus openings and remove any abnormalities blocking the sinuses such as polyps.

If septoplasty is indicated for a deviated septum, an incision is made to the nasal septum inside the nose through one of the nostrils. The mucous membrane is lifted away from the septum. The nasal septum is then reshaped into proper position straightening the septum.

Occasionally severely deviated portions of the septum are completely removed or repaired and replaced inside the nose. Mucous membranes are then returned to their normal position covering the nasal septum.

For an ethmoidectomy procedure, your surgeon will advance the endoscope into the ethmoid sinuses. Special instruments are used to remove diseased tissue and bony partitions to improve airway flow and decrease inflammation.

If the inferior turbinates are large and swollen your surgeon will perform an inferior turbinoplasty. Your surgeon will make an incision in the mucosal lining of the inferior turbinate. The underlying turbinate bone is carefully removed as well as any diseased tissue.

Dissolvable sutures, splints and/or packing are placed inside the nose to minimize postoperative bleeding and a small gauze dressing is taped under the nose.

Post-Operative care:

Following the surgery, your surgeon will give you guidelines to follow depending on the type of surgery performed.

  • Your nostrils will be packed with sterile cotton gauze and will usually be removed before being discharged to home or at your follow up appointment the next day. The gauze dressing under the nose will need to be changed when wet and may be kept in place for a few days.
  • You will be given pain medications to manage your pain. Do not use aspirin or ibuprofen products as these can cause bleeding to occur.
  • Take all medications given to you as prescribed. These may include antibiotics, decongestants, or steroids.
  • Do not drink alcohol while taking antibiotics and pain medications.
  • Get plenty of rest. You should avoid strenuous activity as well as bending and lifting for 1-2 weeks after surgery as this may cause bleeding.
  • Sleep with your head elevated on extra pillows.
  • Sneeze with your mouth open so as not to dislodge the nasal packing.
  • Do not smoke as smoking delays healing and increases your risk of developing complications.

Risks and complications:

As with any major surgery there are potential risks involved. It is important that you are informed of these risks before the surgery takes place. These include:

  • Allergic reactions
  • Blood loss
  • Heart attacks, strokes, kidney failure, pneumonia, bladder infections
  • Infection or nerve damage

Possible complications following sinus surgery can include the following:

  • Bleeding
  • Infection
  • Numbness
  • Meningitis
  • Symptoms Recur

Advantages

Endoscopic Sinus Surgery offers many benefits over the older surgery techniques of “open surgery” where an outside incision was required.

Advantages of endoscopic surgery include:

  • Minimal soft tissue trauma
  • Less pain
  • Faster healing time
  • Lower infection rate
  • Less scarring
  • Usually performed as outpatient day surgery

Nasal Refinement (Rhinoplasty)

Rhinoplasty is a surgical procedure performed to repair or reshape the nose. It can improve the size, shape and the angle of the nose and create a proportion with the rest of your face. It is also performed to correct structural problems with the nose. There are two main rhinoplasty techniques:

Open rhinoplasty

Open rhinoplasty, also called external rhinoplasty, is an approach of rhinoplasty in which a small incision is made on the nose, over the columella between the nostrils, in addition to several other incisions inside the nose. The transcolumellar incision improves the surgical access to the nasal framework by allowing the surgeon to fold the nasal skin upward. This provides better visibility of the entire nasal framework, in its natural undisturbed alignment. Open rhinoplasty can be performed in patients with thick or thin nasal skin. It is indicated in the following conditions:

  • Major augmentation with tip, columellar, spreader and/or shield grafts
  • Correction of complex nasal deformities such as cleft lip, palate nasal deformity and deviated septum or nasal trauma
  • Revision rhinoplasty
  • Excision of nasal tumor
  • Treatment of internal nasal valve dysfunction
  • Nasal tip modification
  • Surgical repair of septal perforations
  • Rhinoplasty in non-Caucasian ethnic groups
  • Closed rhinoplasty

Closed rhinoplasty, also known as endonasal rhinoplasty, is an approach of rhinoplasty where all the surgical incisions are made inside the nose without any external incisions.  Closed rhinoplasty is employed for the correction of aesthetic deformity of the nose as well as for the management of anatomic nasal airway obstruction.

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Nose Augmentation

The nose is the most prominent structure on the face. Even small improvements in the contour of the nose can improve the symmetry and beauty of the face, boosting self-image and confidence.

Nose augmentation, also known as augmentation rhinoplasty is the surgical reshaping of the nose performed for both esthetic and functional concerns. Augmentation helps improve the appearance and size of the nose, and correct difficulty in breathing caused by structural deformities. This form of plastic surgery can change the nose size, asymmetry and deviations, width, humps and depressions on the nose bridge, shape of the nasal tip, and the size and shape of the nostrils.

Indications

Nose augmentation surgery is performed to make the nasal bridge more prominent by increasing its height. The procedure is indicated for the following:

  • Nose deformities, which include a lack of projection of the dorsum and/or tip
  • Defects or irregularities of the nasal sidewalls
  • Congenital defects
  • Defects secondary to infectious and inflammatory conditions such as Wegener’s granulomatosis
  • Post-traumatic defects that result from a crushing injury to the nose structures or from septal hematoma
  • Surgical defects post tumor ablation and excessive reduction after previous rhinoplasty

Surgical procedure

Nose augmentation surgery is performed under general anesthesia or IV sedation, either as a closed or an open technique. In a closed technique, small incisions are made inside the nose, whereas in an open procedure, incisions are made in the columellar skin (strip of tissue between the nostrils). Your surgeon then gently lifts the soft tissues to gain access to the structural defect of the nose. Various tissues can be used as grafts to reduce or enhance the structures of the nose. Grafts may be harvested either from the same patient (autograft), from a donor (homograft), or manufactured from synthetic or semi-synthetic materials (alloplast). The material of choice depends on the case. Once the necessary modifications are made, the soft tissues are re-approximated onto the augmented nasal framework and the incisions are closed with absorbable sutures.

Post-operative care

Follow the specific post-surgical instructions as guided by your surgeon for a quick recovery:

  • A small post-operative splint will be placed on your nose for 5-8 days to protect the new structures during the healing phase.
  • The packing placed inside the nose during surgery is removed 1 or 2 days after surgery.
  • You will be prescribed medications to reduce pain and infection.
  • You may have puffiness, bruising and swelling in your face for 2-3 days after surgery. Apply ice wrapped in a towel over the face to reduce swelling.
  • Refrain from blowing your nose 2 to 3 weeks from surgery.
  • Return to normal activities once you feel comfortable and a follow-up appointment should be scheduled after surgery to check your healing.

Risks and complications

The complications of nose augmentation include infection, bleeding, rupture of small surface vessels of the nose, poor wound healing, persistent pain, nose asymmetry, and nasal airway alterations, some of which may necessitate revision surgery.

Nose Implant

Nose implants are used in nasal reconstruction for correction of aesthetic deformities or nasal obstruction caused by trauma, autoimmune disease, cancer or infection. An ideal nose implant should be inert, non-toxic, non-carcinogenic, sterilizable, easy to sculpt, easily camouflaged, adequate volume and strength, allow favorable interaction with surrounding tissue, maintain its shape and form over time and should resist trauma, infection and extrusion. Moreover, it should be readily available, inexpensive and also easy to remove, if required.  However, an ideal implant does not exist. Thus a favored implant is one which satisfies most of these qualities and suits the individual’s requirements.

Various materials can be used for nasal reconstruction. These may be harvested either from the same patient (autograft), from a donor (homograft) or manufactured from synthetic or semi-synthetic materials (alloplast).

Autograft

Autograft may be harvested from the cartilage (septal, conchal, costal), bone (iliac crest, calvaria) or soft tissue (fascia, dermis) of the same patient. These are most often preferred over other implant materials as there is no risk of incompatibility, rejection or toxicity.

Nasal septal cartilage is the most preferred autograft material for nasal reconstruction, when available in sufficient quantity and quality. The advantage with nasal septal cartilage is that it can be harvested from the same surgical site. Conchal cartilage is the second choice for cartilage as it is available in larger quantities than septal cartilage. However, costal cartilage is usually not preferred as the harvesting of the rib is associated with significant donor site morbidity and a high rate of resorption or warping (twisting) after implantation.  Bone graft is also not preferred usually because of its various drawbacks. Soft tissues such as fascia, dermis and fat are sometimes used for volume augmentation, to hide minor irregularities or also over other implant materials as an onlay graft.

Homograft

Homografts include irradiated rib cartilage and cadaveric dermal grafts. Rib cartilage is preferred by some surgeons for structural grafting whereas cadaveric dermal grafts are used as onlay graft or to hide minor irregularities.

Alloplasts

Alloplasts are now being increasingly used as nasal implants. They are made up of synthetic polymers and include the following:

Silicone implants

Silicone implants are made up of silicone rubber and have been in use for many years. However, their use is limited by the high rate of extrusion and excessive mobility because they do not interact with the host tissue due to their non-porous nature. In Asians, who possibly have thicker skin, they have shown some good results.

Expanded-polytetrafluoroethylene (e-PTFE) implants

e-PTFE is a micro-porous polymer with the pore size of about 22 micrometers. This allows for some host tissue ingrowth, sufficient enough to stabilize the implant while still allowing for graft removal if required. e-PTFE is soft and flexible and thus is primarily used for volume enhancement but it is not recommended as a structural graft.

Porous High Density Polyethylene (PHDPE) implants

PHDPE implants are made up of PHDPE polymer which is easy to sculpt into a desired shape. Moreover, PHDPE polymer contains pores with sizes ranging from 100-250 micrometers which allows for significant host tissue ingrowth. Thus they are used for both nasal soft tissue augmentation and for structural support. Moreover, they are also used for implants for other areas of the face and are available in various shapes and sizes. The only disadvantage is difficulty in removal of implant, if needed.

Meet Our Providers

Robert DeFatta

Robert J.DeFatta
M.D. PhD

Facial Plastic Surgeon

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Rima Abraham

Rima A. DeFatta
M.D.

Otolaryngologist

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Trista M. Williams

Trista M. Williams
Au.D., CCC-A, FAAA

Audiologist

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