The maxillary sinuses are the largest paranasal sinuses, located beneath the eyes within the cheekbones. These pyramid-shaped, air-filled cavities reduce skull weight, humidify inhaled air, and increase vocal resonance. Each sinus drains mucus into the nasal cavity through a small opening called the ostium. Surgery is typically reserved for patients whose symptoms persist despite maximal medical treatment, such as antibiotics, oral steroids, and nasal sprays. The goal of the procedure is to restore normal sinus function by improving drainage and ventilation.
Why Maxillary Sinus Surgery Is Performed
Surgical intervention is typically considered when chronic inflammation and blockage of the maxillary sinuses do not respond to medical therapy. The most frequent indication is Chronic Rhinosinusitis (CRS), defined as sinus inflammation lasting 12 weeks or longer. Surgery aims to remove the anatomical obstructions that prevent the sinus from draining properly, allowing topical medications to reach the affected areas more effectively.
Nasal polyps, which are non-cancerous growths, often require surgical removal to clear the drainage pathway and improve the sense of smell. Surgery also addresses certain types of fungal sinusitis, where fungal balls (mycetoma) are trapped within the cavity.
Other indications include the removal of benign or malignant tumors originating in the sinus. A specific indication is Odontogenic Maxillary Sinusitis (OMS), where an infection spreads from a diseased upper tooth root.
Common Surgical Techniques
The standard approach for addressing the maxillary sinus is Functional Endoscopic Sinus Surgery (FESS), a minimally invasive technique performed entirely through the nostrils. The surgeon uses an endoscope, a thin tube equipped with a camera and light, to visualize the nasal passages and sinuses. This allows for a targeted procedure, typically involving a Maxillary Antrostomy, which enlarges the natural drainage opening (ostium).
FESS involves removing the uncinate process, a small bony structure, to access the natural drainage pathway. Specialized instruments are used to remove bone and tissue blocking the sinus, creating a wider opening into the middle meatus of the nasal cavity. This technique is favored because it aims to restore the natural function of the sinus lining.
A less invasive alternative for select patients is Balloon Sinuplasty, often performed in the office using local anesthesia. This procedure employs a flexible catheter with an inflatable balloon guided into the blocked sinus opening. The balloon is gently inflated to widen the passageway without removing bone or tissue. Balloon Sinuplasty is typically used for mild to moderate chronic sinusitis without extensive polyps or complex anatomical issues.
For more complicated cases, such as massive polyposis, extensive fungal disease, or tumor removal, the older Caldwell-Luc procedure may be used. This technique involves making an incision in the gum above the upper teeth to create a window into the anterior wall of the maxillary sinus. This external approach provides direct access to the entire sinus cavity to remove severely diseased lining or foreign bodies.
Pre-Surgical Preparation
Pre-surgical preparation confirms the nature and extent of the sinus disease. A Computed Tomography (CT) scan is required, providing a detailed map of the sinus anatomy and identifying the blockage location to help plan the surgical approach. Patients will also have a pre-operative appointment with the surgeon and anesthesiologist to ensure medical clearance.
Patients are commonly prescribed pre-operative medications, such as oral steroids or antibiotics, to reduce inflammation and optimize the sinus lining before the operation.
Adjusting regular medications is crucial to minimize the risk of bleeding. Blood-thinning agents must be stopped, usually two weeks prior to the procedure. These include:
- Aspirin
- Ibuprofen
- Naproxen
- Certain herbal supplements like ginkgo biloba
Patients must not eat or drink anything after midnight the night before surgery, a standard requirement for general anesthesia. Smokers are strongly advised to stop several weeks before the procedure, as smoking impairs healing and increases the risk of scarring. Final preparations include arranging transportation home and purchasing a saline rinse kit for post-operative care.
Post-Operative Recovery and Care
The recovery process begins immediately after the procedure, which is generally performed on an outpatient basis. For the first week, patients should expect temporary symptoms such as nasal congestion, mild facial pressure, and some bloody discharge. Fatigue is also common for the first few days due to the effects of anesthesia and the body’s response to surgery.
Nasal saline irrigations, typically using a high-volume rinse system, are essential and usually begin the day after surgery, performed two or more times daily. This process flushes out blood clots, thick mucus, and debris, helping prevent crusting and scarring that could re-obstruct the newly opened sinus.
Activity restrictions reduce the risk of post-operative bleeding and pressure changes. Patients must avoid strenuous activity, heavy lifting (over 10 to 15 pounds), and straining for at least one to two weeks. Blowing the nose is strictly prohibited for at least the first week, and any sneezing should be done with the mouth open to equalize pressure.
Follow-up appointments are scheduled shortly after surgery, often within the first week, for endoscopic debridement. During this in-office procedure, the surgeon gently removes any crusting or residual scar tissue to ensure the sinus opening remains patent. Prescribed medications, including pain relief and antibiotics, should be taken as directed, and non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided for several weeks because they can promote bleeding.