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In the course of a month, I see many patients that are considering sinus surgery. Many have had a CT scan and have been referred to an ENT doctor by a friend or primary care doctor. When I see them, I evaluate them and perform a thorough history and physical exam. I may perform nasal endoscopy in the office. And I usually review a CT scan that the patient already has had performed.
After I have completed this process, which may take from 15-30 minutes, then I start talking about the diagnosis and treatment recommendations. Usually there are several diagnoses–sometimes it is sinusitis, and often its some other diagnosis. Usually there are more than 3 diagnoses, that is more than 3 different problems occurring. As you can imagine, the discussion of the diagnoses and the medical and/or surgical treatments can take another 10-15 minutes.
After all of that, if they are indeed surgical patients, then we talk about the sinus surgery and schedule it if they wish to proceed with surgery.
And frankly, most of the patients I see for a second opinion do NOT need sinus surgery. Many have simply not had a thorough assessment of their symptoms, so the underlying problems have not been identified or treated.
All this is to say, there are a LOT of people who have been recommended to have sinus surgery, who probably don’t need it.
What are some of the most common reasons that I tell patients NOT to have sinus surgery? We’ll do a “top 10” list, with #1 being the most important, in my opinion.
#10. You have recurring acute infections and underlying allergies, but the allergies have not been diagnosed or treated. If you have underlying nasal allergies and don’t treat them, you will get frequent sinus infections. If you treat the allergies, you may not need sinus surgery. If your doctor did not ask questions about allergies, ask the doctor.
#9. You have sinus infections that require frequent antibiotics, with symptoms that recur when you come off antibiotics, but your CT scan (during an infection) shows minimal changes. If you have sinusitis, your CT scan during an infection should so LOTs of mucosal thickening or abnormalities. If it doesn’t see #10 about, about allergies, and also see if you have sicca syndrome (dry eyes and dry mouth). Patients with Sicca syndrome get dry nose, crusting, and bacterial infections of the nose–not the sinuses. Opening the sinuses will often just make things worse.
#8 Your CT scan shows mucosal retention cysts only, and you don’t get frequent infections with lots of yellow green nasal discharge. Mucosal retention cysts are common and of no clinical significance the VAST majority of the time. Be very careful about proceeding with surgery if there are only cysts. This is a common mistake.
#7 Your CT scan shows “minimal mucosal thickening” or “scattered mucosal thickening” consistent with chronic sinusisits (and you don’t get lots of infections with lots of yellow green discharge and nasal blockage). “minimal mucosal thickening” or “scattered mucosal thickening” is potentially consistent with chronic sinusitis, but REALLY, its also consistent with a variant of normal, with the common cold, or with allergies. If you don’t have a strong history of sinusitis (see this blog to help), and your scan has minimal disease, really question your surgeon about the benefit of surgery. Maybe ask “could this be something else?”
#6 You have minimal changes on the CT scan (see above) and severe headaches, which rate >7 on a scale of 10 for severity. If a person has that bad a headache from sinusitis (which is rare) , then they usually have a lot of disease on CT scan. People with headaches > 7 on a scale of 10 are very likely to have some other sort of headache disorder. The most common “other headache” is migraines. Read about migraines, or consider asking your surgeon “could this be migraines”.
#5 You have a normal CT scan and “chronic sinusitis”. If you have chronic sinusitis (that is sinusitis lasting more than 3 months), you simply should not have a normal CT scan. Period. Read more of this blog.
#4 You have had prior sinus surgery for headaches, and your headaches are not better, and your CT scan shows minimal disease. Again, ask your doctor it this could be some other headache disorder. Or ask what your surgeon really thinks the chance of “headache cure is”. Read about migraines.
#3 Your surgeon did not take a thorough history. If you go to an ENT doctor with complaints of sinusitis, and the surgeon takes a very brief history (asking only about infections and antibiotics, for instance, but not allergies, asthma, other treatments, other medical conditions), consider a second opinion. If you think allergies may be a component and your surgeon doesn’t discuss this to your satisfaction, consider getting an allergists opinion.
#2 Your surgeon schedules you for many separate procedures and you don’t understand why each separate procedure is necessary. For instance, you go to see your surgeon for nasal obstruction (and few infections, or no major problems with yellow green nasal discharge), and your CT scan shows minimal or no sinus disease. If your surgeon schedules you for septoplasty, turbinate surgery, and sinus surgery—Get a second opinion! If the surgeon schedules you for surgery on all 8 sinuses, and your CT scan report shows minimal disease, STOP, and get a second opinion.
#1 You have a gut sense that something isn’t right. This is very important. For instance, if the doctor looks at your CT scan, spends 4 minutes talking to you in the exam room, schedules surgery, and leaves you to his staff to negotiate the details, get a second opinion. The surgeon may be right. You may need surgery, but you’re not likely to feel comfortable, and there’s a pretty good chance surgery might be avoided. Get another opinion.
You’d be amazed how many people experience this #1 reason or any of the others. Many experts at leading institutions believe that sinus surgery is performed too often.
I hope this blog post will stimulate you to think about your sinus condition and read more. Remember, these are general guidelines and not medical advice for your particular condition.
If you like this sort of topic, or if you have serious medical conditions and want to optimize your visits with your doctors, you might like the book “How Doctors Think“, by dr. Jerome Groopman.
Jeffrey E. Terrell, MD
Michigan Sinus Center, Ann Arbor, MI