Do You Really Need Surgery for Sinusitis? Expert Insights

Is surgery always necessary for sinusitis?

Hello Dr.
Lee! I finally had the root of my upper right second molar extracted in July, which resulted in an oral-antral fistula.
After contacting the hospital twice, they still deemed it normal and advised against a follow-up visit.
However, I noticed abnormal symptoms and went to another hospital on the sixth day (after the weekend), where a doctor assessed the situation and performed a repair.
By the end of August, I still felt a swelling sensation in my maxillary sinus when drinking water or rinsing my mouth, and there was a subtle pain near my right zygomatic bone.
At the beginning of September, I visited another oral surgery department (after returning to Taipei for school) and started treatment with antibiotics and antihistamines (Pulmicort tablets and Allegra, twice a day; the latter has side effects including upper respiratory infection, chest tightness, shortness of breath, difficulty or labored breathing, nasal congestion, runny or stuffy nose, nervousness, and viral infections such as cold and flu) until October 22.
Starting September 23, I experienced a loss of smell, slight nasal congestion, followed by mouth sores and a sore throat (foreign body sensation, tearing), along with a mild cough.
On September 28, I consulted an infectious disease specialist and took a five-day course of cough suppressants and antipyretic analgesics: Robitussin DM capsules and Tylenol; however, the "cold symptoms" became more pronounced, with severe coughing (persistent cough), runny nose, and thick phlegm that was difficult to expel (with gurgling sounds of phlegm moving in the trachea), and my nose became completely congested, making it hard for my lungs and heart.
On October 9, I experienced significant strain on my heart and lungs, with wheezing, and for the first time in my life, my pulse dropped to 52! Subsequently, I experienced new lows: 47, 45, 41, 40 (on October 24)..., 46 (on October 26), and I still occasionally have low pulse phenomena.
On October 15, I visited the ENT department, and X-rays and CT scans revealed sinusitis (with a cloudy appearance and obstruction on the left side).
After a week of antibiotics and expectorants (Nocoderm coated tablets and Aiketan granules), my symptoms disappeared.
However, at this point, the doctor recommended surgical treatment for sinusitis.
Since I have no experience with general anesthesia, and aside from occasionally sneezing, having a runny nose, or nasal congestion (which happens very rarely—once every few years, with the last cold on January 5, 2016), I do not typically exhibit any symptoms of "sinusitis." Currently, I do not have nasal congestion, sneezing, or a runny nose (nor have I experienced "yellow nasal discharge," nasal swelling, or a feeling of heaviness).
Dr.
Lee, what is your opinion? My right maxillary sinus (oral-antral fistula) issue has improved significantly; the oral surgeon said no further follow-up is needed, and I should rest and protect it, as it will take about 4-6 months for the bone membrane to heal.
However, the ENT doctor insists that I undergo surgery for the left maxillary sinus, stating that the cloudy appearance on the left side is more pronounced, while the oral surgeon noted some inflammation in the left sinus but believes it will gradually recover.
The X-ray and CT scans were taken a week prior to the follow-up visit, during which I still had cold symptoms (nasal voice, slight swelling and heaviness in the nose, coughing).
Thank you for your clarification!

Dr. Hsieh, 50~59 year old female. Ask Date: 2018/10/28

Dr. Li Jiaxuan reply Otolaryngology

If you are afraid of surgery, you can wait until the bone at the site of the sinus connection grows back before proceeding with surgery for your sinusitis.
Currently, conservative treatments for sinusitis include medications (antihistamines and antibiotics) and nasal irrigation.
Please also avoid catching a cold, as acute inflammation could lead to a situation similar to what you experienced on October 9, where sometimes an acute infection may require emergency surgery.
Wishing you safety and good health.

Reply Date: 2018/10/28

More Info

When considering surgery for sinusitis, particularly in the context of your recent dental surgery and ongoing symptoms, it's essential to weigh the benefits and risks carefully. Sinusitis, or inflammation of the sinus cavities, can be acute or chronic, and its management often depends on the severity and duration of symptoms, as well as the underlying causes.

In your case, it seems that you have experienced a series of complications following the extraction of your upper second molar, which led to a connection between your oral cavity and sinus cavity. This can lead to sinusitis, as bacteria from the mouth can enter the sinus cavities, causing infection and inflammation. Your symptoms, including nasal congestion, cough, and the sensation of fluid in the sinuses, suggest that you may still be experiencing residual effects from this condition.

The decision to proceed with surgery for sinusitis typically hinges on several factors:
1. Chronic Symptoms: If you have persistent symptoms that do not improve with medical management (such as antibiotics and antihistamines), surgery may be considered. Chronic sinusitis can lead to complications, including the risk of developing more severe infections or even affecting nearby structures, such as the eyes or brain.

2. Imaging Findings: Your CT scan results indicating "white mist" in the left sinus suggest inflammation or fluid accumulation. If this is significant and correlates with your symptoms, surgery might be warranted to clear the blockage and allow for proper drainage.

3. Response to Treatment: Since you mentioned that your symptoms improved with antibiotics but returned, it raises the question of whether the underlying issue has been fully addressed. If medical treatment fails to provide lasting relief, surgical intervention may be necessary to resolve the anatomical issues contributing to your sinusitis.

4. Quality of Life: If your symptoms are significantly impacting your daily life, such as causing sleep disturbances or chronic fatigue, surgery might be a reasonable option to consider.

5. Risks of Surgery: While surgery can be effective, it is not without risks. Potential complications include bleeding, infection, and adverse reactions to anesthesia. Given your lack of experience with general anesthesia, discussing these concerns with your surgeon is crucial. They can provide insights into what to expect and how to prepare.

6. Consultation with Specialists: It may be beneficial to seek a second opinion from another ENT specialist, especially since you have conflicting opinions from different doctors. A thorough evaluation, possibly including a nasal endoscopy, can provide more clarity on the necessity of surgery.

In summary, while surgery for sinusitis can be beneficial, it is essential to consider your specific situation, including the persistence of symptoms, imaging findings, and overall health. Engaging in a detailed discussion with your ENT specialist about the potential benefits and risks of surgery, as well as exploring all available treatment options, will help you make an informed decision. If surgery is recommended, ensure that you understand the procedure, recovery process, and any necessary follow-up care to optimize your outcomes.

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