Chronic sinusitis: when is surgery actually needed?

What is the difference between acute and chronic sinusitis?

Sinusitis is inflammation of the air-filled spaces around the nose (the sinuses). It usually follows a cold and settles on its own or with short treatment. In chronic sinusitis, symptoms last for weeks or months and the inflammation becomes persistent.

Chronic sinusitis is not diagnosed on symptoms alone. Nasal blockage or discharge, together with facial pressure or a reduced sense of smell, should last longer than 12 weeks and be confirmed by nasal endoscopy or a CT scan. Several acute attacks a year is a different picture and is assessed separately.

How long should medical treatment be tried?

The foundation of treatment is regular care that reduces inflammation inside the nose. For most patients we start with:

• Saline rinses: They clear mucus and crusts and help keep the sinus openings clear. High-volume rinsing with a squeeze bottle is usually more effective than a simple saline spray.
• Steroid nasal sprays: They reduce inflammation and swelling of the lining. The effect builds over several weeks, so regular use with the correct technique matters.
• Treating related factors: Allergies, reflux and smoke exposure make it harder to get results if they are left uncontrolled.
• Short courses of additional medication in selected cases: Antibiotics for a bacterial flare-up, or a short course of oral steroids for marked polyps, are planned after a doctor's assessment.

Decongestant sprays are meant for a few days only; long-term use can itself cause persistent blockage. To judge whether medical treatment works, regular use over a period of several weeks to a few months is usually needed. In a large share of patients, symptoms improve to an acceptable level at this stage.

When is a CT scan done?

A sinus CT scan shows how widespread the disease is and the anatomy of the sinus openings. It is not the first step for every blocked nose. It is usually requested when symptoms persist despite medical treatment or when surgery is being considered.

A scan taken during a cold can be misleading, because temporary swelling can look like lasting disease, so we time it according to the examination. If surgery is planned, the CT also serves as a road map during the operation.

When is endoscopic sinus surgery (FESS) considered?

Functional endoscopic sinus surgery (FESS) is performed through the nostrils using a thin camera: blocked sinus openings are widened and diseased tissue is removed. There are no external incisions on the face. It may be considered in cases of:

• Persistent symptoms despite adequate, correctly used medical treatment,
• Sinus openings that remain blocked on CT,
• Nasal polyps that do not shrink enough with medication,
• Recurrent sinusitis attacks several times a year that clearly affect daily life,
• Special situations such as fungal sinusitis, a suspected one-sided mass, or complications spreading towards the eye or brain.

If a deviated septum impairs ventilation of the sinuses, a septoplasty can be done in the same session. If you would also like the outer shape of the nose changed, this can be planned together as a septorhinoplasty.

Do nasal polyps change the picture?

Chronic sinusitis with polyps is a form in which polyps fill the nose and often cause loss of smell. Here too, medical treatment is usually the first step. Surgery removes the polyps and opens the sinuses, which helps nasal sprays reach them afterwards.

A tendency to form polyps is, however, an underlying condition: regular spray use and follow-up remain necessary after surgery, and in some patients polyps return over the years. Especially in patients with asthma or recurring polyps, newer options such as biologic medicines may be considered where appropriate.

What is recovery like after surgery?

FESS is usually done under general anaesthetic, and most patients go home the same day or after one night in hospital. The length of the operation depends on the extent of disease.

In the first days, nasal blockage, slightly blood-stained discharge and crusting are common. Most people return to desk work within about a week. For the first one to two weeks we recommend avoiding blowing your nose, strenuous exercise and straining. Saline rinses and the cleaning done at follow-up visits are an important part of healing; full recovery of the lining can take several weeks to a few months. If you are travelling to Izmir, we usually suggest staying around a week so the first check-up can take place before you fly home.

As with any operation, there are risks such as bleeding, scarring inside the nose (adhesions) and recurrence of disease. Serious complications involving the eye or skull base are rare, and we discuss them in detail before surgery.

When to see a doctor

If nasal blockage, postnasal drip or a reduced sense of smell lasts longer than three months, an ENT examination is worthwhile. One-sided, worsening blockage or blood-stained discharge should always be checked. Seek urgent care without delay if sinusitis comes with swelling or redness around the eye, changes in vision, severe headache, a stiff neck or high fever.

The decision to operate on chronic sinusitis is never based on a single scan or a single visit. We assess your symptoms together with endoscopic findings and, where needed, a CT scan, and plan the right next step with you. You can also find more answers on our frequently asked questions page.