SINUSES

The air-filled cavities located within the bones surrounding the nose are called sinuses (paranasal sinuses). There are five pairs of sinuses: maxillary sinuses (cheek sinuses), frontal sinuses (forehead sinuses), anterior and posterior ethmoid sinuses (between the eyes), and sphenoid sinuses (intracranial sinuses) (Figure 1). The mucosa lining the inside of the nose also lines the inside of the sinuses, and the glands in the mucosa of the sinuses produce 0.5-1 liter of mucus during the day. This mucus is transported towards the narrow channels called ostia, which connect the sinuses to the nose, by the movements of microscopic cilia called silia on the mucosa, and is then drained into the nose through these channels. The substances in the mucus help the body’s defense system against microbes, while also playing a role in filtering particles in the inhaled air and humidifying the air before it reaches the lungs.

SINUSITIS – RHINOSINUSITIS

Any inflammation of the sinuses surrounding the nose is termed “sinusitis.” Sinusitis results from the inability to drain the mucus produced by the sinuses into the nose due to blockage of the drainage channels (ostia) or disruption of the mucus transport system (mucociliary activity).

Due to the embryological and anatomical continuity of the mucosa of the nose and sinuses and their similar responses to medical and surgical treatments, the term “rhin sinusitis” has become more commonly used instead of “sinusitis.”

Rhin sinusitis is categorized into four groups based on the duration of symptoms and the complaints they cause.

  • Acute rhin sinusitis: sinusitis that starts suddenly and resolves completely within 4 weeks.
  • Subacute rhin sinusitis: acute sinusitis that lasts more than four weeks but resolves before 12 weeks.
  • Recurrent acute rhin sinusitis: the occurrence of four or more acute sinusitis episodes within a year, each resolving within at least 7 days.
  • Chronic rhin sinusitis: sinusitis that lasts longer than 12 weeks, which may include acute sinusitis attacks intermittently.

CAUSES OF RHINOSINUSITIS

Rhin sinusitis occurs through the interaction of patient and environmental factors. In all groups, the most common cause is viral upper respiratory infections (URI). The edema and inflammation of the nasal mucosa, along with the production of thick mucus that blocks the sinuses, lead to secondary bacterial proliferation.

Mucosal edema caused by allergies blocking the sinus ostia is the second most important cause of rhin sinusitis. Anatomical pathologies that block sinus drainage channels, such as nasal septum deviation, polyps, and turbinate hypertrophy, can also cause rhin sinusitis. Cystic fibrosis or ciliary motion disorders that disrupt mucus production or transport are rarely observed. Additionally, HIV infection, chemotherapy, immunosuppressive use, insulin-dependent diabetes, and some collagen tissue diseases can affect the immune system and lead to rhin sinusitis.

HISTORY AND EXAMINATION

In rhin sinusitis, the complaints and findings identified during history taking and examination are categorized into two groups: major complaints and findings with primary diagnostic importance (facial pain and pressure, facial swelling and fullness, nasal obstruction, purulent discharge from nose and postnasal drip, anosmia, and fever) and minor complaints and findings with diagnostic significance (headache, bad breath, malaise, toothache, cough, earache).

In the supine position, the increase in blood volume and edema in the paranasal mucosa negatively affects mucociliary activity, resulting in more pronounced symptoms at night and early morning.

Chronic rhin sinusitis typically presents with mild symptoms and is difficult to diagnose based solely on history. Generally, the most meaningful complaints are posterior nasal discharge, postnasal drip, and sinus tenderness. In individuals with a history of allergic rhinitis, mild complaints and examination findings should suggest allergy rather than infection. In patients suspected of sinusitis, a physical examination should carefully investigate facial swelling, redness, and edema (especially around the eyes), enlarged lymph nodes, and purulent discharge at the back of the nose.

During nasal examination, signs such as mucosal edema and redness, purulent crusting, purulent discharge, polyps, or anatomical abnormalities blocking the sinus drainage channels in the middle meatus may be observed.

Inflammatory discharge observed during examination of the posterior part of the nose (nasopharyngeal examination) is particularly important in diagnosing chronic rhin sinusitis. In patients where pathological findings are not detected during examination, pathological conditions of the sinuses draining into these areas can be identified through nasal endoscopy of the middle and upper meatus.

LABORATORY

The value of laboratory tests in diagnosing rhin sinusitis is limited. For the differential diagnosis of allergic rhinitis, especially when mixed with mild rhin sinusitis, serum IgE levels and allergy-related blood or skin tests can be performed. The presence of dense white blood cells (leukocytes) in nasal discharge under microscopic examination can indicate viral or bacterial rhin sinusitis, while the presence of eosinophils, plasma cells, and mast cells can aid in diagnosing allergic rhinitis.

If diseases such as sarcoidosis, Kartagener syndrome, Sjögren syndrome, Wegener’s granulomatosis, and polyarteritis nodosa are suspected, mucosal biopsies should be performed.

In cases of frequent recurrent resistant rhin sinusitis accompanied by other head and neck infections such as otitis, tonsillitis, pharyngitis, or furuncles, familial, drug-induced, or HIV infection-related immune deficiencies should be investigated.

In congenital or acquired antibody deficiencies, recurrent infections with encapsulated microorganisms, fungal and viral infections in cases of T-lymphocyte disorders, and recurrent infections with gram-negative microorganisms in complement system disorders are observed. In such cases, basic tests such as complete blood count, sedimentation rate, and serum immunoglobulins should be conducted.

RADIOLOGY

In diagnosing diseases of the maxillary, frontal, and sphenoid sinuses, it is significant to observe fully opacified sinuses, air-fluid levels, and mucosal thickening exceeding 6 mm in children and 8 mm in adults on plain sinus X-rays. Water’s view is taken for maxillary sinuses, and Caldwell’s view is taken for frontal sinuses.

However, the anterior ethmoid sinuses, which are the initial sites for most sinus pathologies, and the ostiomeatal complex—a key area for the development of rhin sinusitis—cannot be adequately evaluated with plain X-rays. Nowadays, the preferred diagnostic method for diagnosing and planning treatment for chronic and severe acute rhin sinusitis is a paranasal sinus computed tomography (CT) scan with 3-4 mm slice intervals.

Magnetic resonance imaging (MRI) is not preferred for diagnosing sinusitis except in cases where there is suspicion of infection spreading into the brain, due to its inadequacy in evaluating bone tissue and its high cost.

MICROORGANISMS CAUSING SINUSITIS

In acute rhin sinusitis, viral agents (mainly rhinoviruses, influenza, and parainfluenza viruses) are responsible in approximately 15% of cases. Bacterial agents, in order of frequency, include pneumococci, Haemophilus influenzae, anaerobes, Staphylococcus aureus, Streptococcus pyogenes, and Moraxella catarrhalis.

In long-term subacute or chronic rhin sinusitis, the order is as follows: coagulase-negative staphylococci, S. aureus, anaerobes, and pneumococci. It has been reported that in chronic rhin sinusitis, multiple microorganisms are detected in about 16% of cases.

The rate of beta-lactamase resistant bacteria is around 30% in acute rhin sinusitis cases that have not been treated with antibiotics, while in chronic cases, it exceeds 50%. About 2-7% of chronic rhin sinusitis cases fall into the allergic fungal sinusitis group. In this pattern, especially in patients with allergic constitutions and asthma, dense nasal polyps and fungal clusters are observed, and opacified sinus appearances are seen in radiological examinations.

TREATMENT OF SINUSITIS

A. Medical Treatment

Providing a moist environment inside the nose and cleaning accumulated crusts and purulent secretions are the most important components of supportive therapy. Physiological saline-containing sprays are the most suitable agents for this purpose. In cases of bacterial carriage that cannot be prevented with orally or injection-administered antibiotics, antimicrobial agents (Basitrasin 250,000 U/L or Gentamycin 160 mg/L) can be added to these solutions.

The main groups of medications used in treatment are as follows;

  • Mucolytics that increase the fluidity of mucus: They are used to prevent the accumulation of mucus caused by disrupted ciliary activity and production of thick mucus that carries mucus from the sinuses. They facilitate nasal and sinus drainage by thinning secretions. Medications containing guanifensin, acetylcysteine, or ambroxol hydrochloride can be used for this purpose.
  • Decongestants that reduce mucosal swelling: They can be used nasally (spray) and orally. They constrict the blood vessels in the mucosa, thinning the mucosa, thereby widening the sinus ostia, increasing sinus drainage, and enhancing air entry. Decongestant agents used as sprays, such as phenylephrine, xylometazoline, and oxymetazoline, are recommended not to be used for more than 4-5 days due to their rebound vasodilation effects and irritative effects on the mucosa over time. Oral decongestants like pseudoephedrine and phenylpropanolamine can be safely used throughout the duration of the illness; however, they should be avoided in individuals with hypertension, coronary artery disease, hyperthyroidism, diabetes mellitus, and those taking MAO inhibitors, as they can cause severe side effects.
  • Antihistamines that reduce allergic reactions: They increase mucus viscosity and hinder sinus drainage. Therefore, they are not recommended for use outside of allergic rhin sinusitis.
  • Intranasal corticosteroid sprays that reduce inflammation and allergic reactions: They are used to reduce mucosal edema and inflammation-related reactions in chronic rhin sinusitis and allergic patterns.
  • Short-term oral steroid use: In allergic individuals and especially in chronic rhin sinusitis with polyps, using steroids for 7-10 days before surgery can facilitate surgery by reducing polyp size and inflammation.
  • Antibiotics: In non-specific acute rhin sinusitis, treatment is generally applied without taking cultures. The choice of medication can be based on the resistance patterns of antibiotics in the community, patient adherence to drug dosing, hypersensitivity to drugs, variable side effects of each antibiotic, and drug interactions. Since more than two-thirds of acute rhin sinusitis cases are caused by pneumococci or H. influenzae, antibiotics should be selected based on their efficacy against these agents. Commonly preferred antibiotics include amoxicillin, amoxicillin-clavulanic acid, clarithromycin, cefuroxime, cefprozil, loracarbef, ciprofloxacin, and levofloxacin. Penicillin, cephalexin, erythromycin, and tetracycline are generally not preferred as they do not cover all major causative microorganisms. Additionally, due to the increased resistance to amoxicillin, its use has decreased. The appropriate duration of antibiotic use is 10-14 days; long half-life antibiotics like azithromycin analogs can be used for shorter periods.

In the treatment of chronic sinusitis, the selected antibiotic should be effective against S. aureus and beta-lactamase-producing microorganisms, especially if there is a history of unsuccessful antibiotic use. Initial antianaerobic treatment may not be started, but if no improvement is observed in symptoms within 5-7 days, an agent such as ornidazole or clindamycin should be considered to be added to the treatment. Antibiotics used for acute rhin sinusitis, other than amoxicillin and trimethoprim-sulfamethoxazole, can also be used in chronic rhin sinusitis. The treatment duration should be at least 4 weeks. In chronic rhin sinusitis, considering the rate of resistance, the possibility of multiple or anaerobic microorganisms, and the long treatment duration, treatment should be selected based on the results of cultures taken during endoscopy if possible. Especially in patients with immune deficiencies or infections while hospitalized, antibiotic selection based on cultures and antibiograms should be performed in all types of rhin sinusitis.

In allergic fungal sinusitis, the first treatment option is surgery. After surgery, fluticasone or itraconazole is used for 1-3 months. To prevent inflammatory reactions, oral and then intranasal corticosteroids are recommended during the postoperative period in these patients. Due to the high rate of disease recurrence even after all treatments, immunotherapy is being explored.

SURGICAL DECISION

The definite indications for surgery in rhin sinusitis are;

  • Widespread polyp formation
  • Acute complicated rhin sinusitis
  • Accumulation of abscess under the bone membrane (subperiosteal) or within the eye (orbital abscess)
  • Inflammation in the frontal bone (frontal osteomyelitis – Pott’s puffy tumor)
  • Brain abscess, meningitis
  • Formation of abscess that completely fills and expands the sinus (mucocele-mucopyocele)
  • Allergic fungal sinusitis spreading to surrounding tissues
  • Suspicion of tumors
  • Leakage of cerebrospinal fluid into the nose (CSF leak). Acute complicated rhin sinusitis occurs due to the spread of infection outside the sinuses. In treatment, the infection focus is cleaned endoscopically along with intravenous antibiotics.
  • Relative indications for surgery;
  • Rhin sinusitis not improving despite appropriate and adequate treatment
  • Recurrent rhin sinusitis with the infection focus located
  • Secondary, treatment-resistant rhin sinusitis due to anatomical variations (nasal deviation, differently developing sinus cells, turbinate hypertrophy, etc.)

To confirm that medical treatment has failed, adults should receive 4-6 weeks of treatment, and children should receive 2-3 months of treatment, and the lack of infection resolution should be confirmed with CT scans. If symptoms do not improve despite appropriate treatment and no significant radiological improvement is observed, especially in adult patients with anatomical variations, an earlier surgical decision can be made.

In cases of treatment-resistant rhin sinusitis, obstructive nasal anatomical variations, immune deficiencies, ciliary motility problems, atopy, asthma, diabetes, sarkoidosis, etc., can be effective factors.

Severe heart and lung diseases, cerebral vascular diseases, and coagulation disorders are the main conditions that require avoidance of surgical treatment.

ENDOSCOPIC SINUS SURGERY

Endoscopic Sinus Surgery (ESS) is one of the most commonly performed surgeries today as a current treatment option for chronic sinusitis, tumors, and cranial cavity defects.

In the USA, approximately 200,000 ESS procedures are performed annually for chronic sinusitis, which affects about 14% of the population.

ESS is successfully applied to inflammatory and non-inflammatory diseases of the sinuses and nasal regions. The narrowness and complex anatomy of the areas where the sinuses surrounding the nose are located, along with the proximity to critical organs such as the brain, eyes, optic nerves, tear ducts, and carotid arteries, require high technical skill and low error rates in these surgeries.

The main procedures performed with ESS in chronic sinus diseases include;

  • Removal of inflammatory tissues/polyps
  • Opening of sinus drainage pathways
  • Correction of anatomical deformities such as turbinate bullosa, accessory ostia, and mucosal contact areas.

During ESS, especially in cases where technological devices such as navigation and shavers (microdebriders) are used, general anesthesia is preferred for the comfort of both the patient and the surgeon. The duration of surgery varies depending on the extent of the pathology and whether additional interventions such as correction of nasal deviation, reduction of turbinates, correction of anatomical variations, etc., will be performed in the same surgery. Simple, single-sinus interventions take around 15 minutes, while cleaning pathologies that involve all sinuses can take more than two hours.

If additional interventions like turbinate reduction are not required, no tampon is placed inside the nose after sinus surgery, and patients can breathe comfortably through their noses. Special tampons and various materials placed in the surgical area under the middle turbinate to prevent bleeding and tissue adhesions during the healing process do not adversely affect nasal breathing.

Serious pain complaints are not expected after surgery; simple painkillers are usually sufficient.

While patients are recommended to stay in the hospital on the day of surgery, discharge on the same day is also possible depending on the extent of the surgery.

Postoperative antibiotic therapy continues for at least 10 days, and this duration may be extended or additional medications may be added if necessary. Sterile saline-containing sprays that mechanically clean the nose and humidify the mucosa should be used until crusting is resolved. In allergic and polypoid patients, corticosteroid-containing sprays are started from the second week onwards.

The first dressing for the sinuses after surgery is performed on the 6th-7th day, and this dressing is very important for the success of the surgery. During this approximately half-hour dressing, crusts formed in the nose and sinus drainage channels are cleaned, any materials placed to prevent adhesion inside the sinuses are removed, and infection control is carried out. Patients need to attend 2-4 more follow-ups every 7-10 days until healing is complete, depending on the extent of the surgery.

In ESS, in certain special situations, the difficulty of the surgery increases, and the likelihood of failure or complications also increases. These special situations include;

  • Excessive bleeding during surgery
  • Severe inflammation
  • Some tumors, especially those with high vascular content
  • Hypertension
  • Coagulation disorders (bleeding diatheses) / aspirin use
  • Surgical trauma
  • Anatomy altered due to previous surgeries or trauma
  • Formation of fibrous scar tissue due to previous surgeries
  • Widespread polyps
  • Intranasal/extranasal sinus tumors
  • Anatomical changes (variations)
  • Onodi cell
  • Large Agger Nasi
  • Haller’s cell
  • Pathologies of the posterior ethmoid, sphenoid, and frontal sinuses.
  • During or after ESS, some minor and major complications can occur. The most important among them are;
  • Active bleeding
  • Intraorbital (inside the eye) bleeding
  • Rupture of the carotid (internal carotid) artery
  • Orbital (eye socket) trauma
  • Endophthalmitis (displacement of the eye)
  • Eye movement disorders
  • Trauma to the nasolacrimal canal (tear duct)
  • Leakage of cerebrospinal fluid
  • Cranial complications such as abscess, meningitis, intracranial air leak (pneumocephalus), pituitary gland damage.

Computer-Assisted Sinus Surgery (Surgical Navigation-CN) is a technology that allows the surgical instruments used during paranasal sinus surgery to be tracked in real-time, three-dimensionally, with less than 1 mm error on sinus anatomy images taken preoperatively via a special device and software. It facilitates safer endoscopic sinus surgery, ensures secure access to all diseased areas, significantly increases the success rate of the surgery, and is extremely beneficial in eliminating risks of complications, especially in special cases with high complication risks.

SURGERY COST

There are numerous variables that determine the cost of your endoscopic sinus surgery, the main ones are;

  • Extent of the surgery: unilateral, bilateral surgery
  • Specific sinuses to be operated on: frontal sinus, sphenoid sinus
  • Surgical method: standard surgery, balloon sinusoplasty method, combined surgery
  • Advanced technology to be used: surgical navigation (computer-assisted surgery), microdebrider (shaver)
  • Special materials to be used: Seprafilm, Seprajel, etc.
  • Other surgeries to be performed simultaneously: turbinate reduction, septum deviation surgery, nasal esthetic surgery, etc.
  • Additional materials and technologies to be used in the additional surgery: radiofrequency, nasal splints, etc.
  • The hospital where the surgery will be performed.

Endoscopic sinus surgery is performed without direct vision in a region with critical anatomical proximity, while monitoring images obtained from endoscopic systems on a screen, using small and precise surgical instruments. In addition to surgical knowledge and experience, the quality and adequacy of the available surgical equipment and endoscopic systems, the ability to use special materials and advanced technological devices when needed, have very important effects on the duration of the surgery, success, and prevention of unwanted results (complications). Having all these facilities available does not affect the surgical fee, but it does affect hospital fees, thus affecting the total cost. If you have a limited disease involving only the maxillary sinus and/or anterior ethmoid sinuses, as long as endoscopic systems and surgical instruments are sufficient, your surgery can be performed without the use of additional technology or hospital stay. All other pathologies will require the use of additional technologies to achieve the highest success rate with minimal complication risks, which will affect the cost of your surgery.

If a situation requiring the use of surgical navigation exists, the additional cost of this technology is around 400 USD. However, considering that this cost is offset by the significant reduction in the possibility of needing a second surgery due to thorough cleaning of the existing pathology and the almost elimination of the risk of damaging critical anatomical structures, this technology becomes an indispensable tool. Since navigation devices are a very expensive investment, they are currently only available in certain hospitals.

Microdebrider systems are advanced technological devices that, under endoscopic vision, precisely shave and clean only the diseased tissue while preventing damage to healthy tissue, simultaneously washing the surgical area and cleaning it with vacuum, thereby saving significant time. Especially in cases of widespread disease or polyps, they significantly reduce the duration of the surgery while being effective in thoroughly cleaning the disease and shortening the healing process. The use of this technology incurs an additional cost of approximately 400 USD.

In limited diseases involving the frontal, cheek, and sphenoid sinuses, and in some other special cases, the “Balloon Sinusoplasty” technique is extremely beneficial and frequently preferred due to rapid healing, minimal tissue trauma, and lack of complication risks. In this single-use material surgery, different numbers and types of instruments are used depending on the type of sinuses involved, and the additional cost ranges between 500-1000 USD.

In patients with severe adhesions caused by previous surgeries, materials such as Seprafilm/Seprajel used to prevent the risk of re-adhesion after surgery incur an additional cost of around 250 USD.

Endoscopic sinus surgery is a surgery covered by private health insurance policies unless the onset of your disease predates the start of the insurance policy. The most important criteria for a successful outcome are selecting the right surgeon with sufficient knowledge and experience and having your surgery performed at a center equipped with the necessary special medical materials and technologies based on the condition of your disease. This will significantly contribute to achieving successful results with a single surgery and reducing the risk of postoperative problems. If you do not have private health insurance, the most appropriate approach is to undergo a detailed examination and sinus tomographic evaluation, and determine your surgery cost in parallel with the topics mentioned above based on the detected findings.