Your CT Scan Visit
- How a normal nose and sinus work
- How noses and sinuses quit working
- How we go about helping noses and sinuses that do not work start to work again
- Finally, how this all relates to your nose and sinus problem
First of all, it is important to understand that all of us–young or old, male or female –develop problems with our nose and sinus. However, most of us are able to take some type of medical treatment to relieve or control our symptoms.
On your CT visit, we first started the explanation of how noses and sinuses work by reviewing your CT scan. (For some of you, we have included specific prints that explain and show why your nose and sinus may have some structural problems.)
Remember, normal sinuses are filled with air, which is the color black on the CT scan. The sinus is outlined with white bones, so “black is good and white is good.” Furthermore, most structures should be symmetrical and straight with no contact among structures. As I kidded with you: “Straight is good, crooked is bad.” CT scans are necessary because simple plain x-rays do not show the necessary detail and depth of field of small structural abnormalities that can cause the nose and sinus to “quit working”.
Following the review of your CT scan, we then looked at your nasal endoscopy (scope) on the TV monitor. Most patients are unaccustomed at looking at the inside of the nose; however, with very little prompting, it is usually easy to see when structures are blocked, when the membranes are red, irritated, inflamed or bleeding. Also, frank pus and polyps are easily recognized. The normal membrane of the nose should be pink and moist like your lips and have the color of your fingernails.
Remember, the nose prepares air for our lungs. It does this by heating, cooling, humidifying, dehumidifying and cleaning air for your nasal airway in preparing air for the lungs.
As you recall, the uncinate bone is a critical landmark. Behind it is where the forehead sinus, ethmoid sinus and maxillary sinus drain mucus. There is approximately 2 quarts of mucus a day that has to drain to and through the nose and go down the back of the throat. This river of mucus is critical for helping prepare air for our lungs. For instance, bacteria, viruses and irritants will hit and stick to this mucus river. This river of mucus is then escorted down the back of the throat and the stomach acids dissolve the potentially intruding offenders.
Thus, it is critical to get air though the nose and to have mucus flow freely from the sinuses. There are basically two reasons why there are problems with the nose and sinus. The first is membrane problems. There are many membrane problems. The most common ones are allergy, cigarette smoke, pollen, perfume, pregnancy (hormones), dryness, virus, forest fires, etc. These irritants can cause the mucous membrane to swell, thus blocking the airflow and mucus flow. We have all seen this happen. When we get a viral “cold”, we become plugged up and congested. When mucous membrane swelling blocks the flow of mucus, the mucus then becomes stagnant. Stagnant mucus attracts bacteria and we experience pain and pressure. Yellow-green mucus then drains down the back of our nose and throat.
As this “polluted” river of mucus drains down the back of our throat, it can affect our ears and cause ear pressure, blocked Eustachian tubes, decreased hearing, acute otitus media, ear drum perforations, etc. As the mucus continues down the back of the throat, it can cause sore throat, hoarseness, coughing, and bad breath. Bad breath can be such a powerful “minor problem” as to affect marriages and personal relationships.
Most membrane problems are treated successfully with some type of medication or medical treatment. Antibiotics, allergy shots, cortisone spray, cortisone pills, antihistamines, decongestants, over-the-counter medications, and non-conventional herbs have all been used, and used successfully, in decongesting the nose and sinus. Indeed, this works more than 9 out of 10 times. I joking refer to this as the “9 out of 10” club, for this is the club the most people fall within. Unfortunately, a few in this club understand how inconvenient, uncomfortable and life-altering chronic nasal/sinus problems can become.
When medicines fail it is usually not because the medicine is bad or the physician prescribing the medicine is bad or that you’re a bad person. It is usually because there are structural problems. As I have tried to illustrate in our visit, structural problems can be a deviation of the septum, a spur, a contact, a twist or bend of cartilage that can block airflow and/or mucus flow.
A malformed turbinate, whether it is paradoxical, lateralized by a deviated septum or has an air pocket called a concha bullosa, can affect airflow or collect mucus and cause chronic sinusitis. In addition, these turbinates can push and block the outflow tracts of the maxillary, ethmoid, frontal sinuses and sphenoid sinus.
The ucinate bone can be malformed and can cause problems with the outflow of the maxillary sinus and, in a addition, be in contact with the ethmoid sinus and create difficulties of drainage in this area. Structural problems, in addition to the continued membrane irritations that we all have through life will eventually cause chronic rhinosinusitis. At this point, medicines will have less and less effect. Indeed, medicines can quit working. After many visits to the doctor and trial of many medications,most patients will just “live with it”.
Structural problems require a consideration of surgery. Surgery can fix structural problems, but surgery cannot fix membrane problems. By the time most patients end up at the Sinus Center-Idaho, they have combination of membrane problems and structural problems.
Surgery for structural problems historically has been fraught with a lot of misinformation. Early surgery for the sinus was miserable at best, and could have catastrophic consequences at worst. The early surgeries were done with just an operating headlight and were done with instruments that were traumatic to the nose and sinus tissues. At worst, brain and eye injury could be a consequence of nasal surgery. At best, the trauma of these surgeries usually required 7-10 days of nasal packing.
Now with technology, it is easy with cameras and scopes to see the nasal/sinus areas. Evaluating nasal/sinus structures with the use of a CT scan is very quick and efficient. Now, when surgery is necessary, a powered-precision shaver developed by Dr. Rueben Setliff, is used. With this technique, the structures of the sinus area can be shaved, remodeled, repositioned and corrected with minimal trauma. This instrument is very similar to what orthopedic surgeons insert in arthroscopic knee surgery. In the old days when patients had knee surgery, the knee was opened up widely and cartilage was traumatically removed, leaving the patient with a big scar. Thus, the knee usually took 6 months to a year to resolve. Now arthroscopic knee surgery is done with a scope and a shaver, similar to the one that you have seen in the office, and patients can often resume such strenuous activity as professional athletics in 4-6 weeks.
With similar precision, shaving abnormal structures of the nose and sinus can now be approached and surgically re-engineered for airflow and mucus flow. Because of minimal trauma patients do not require packing. The procedure is done on an outpatient basis. Often patients can return to work in 5-7 days.
The most interesting technology is the computerized software program, called INSTA TRAK, which is compatible with your CT scan. This is used during surgery to navigate through the very small area of the sinus that lies between the brain and eye. Now, anatomical landmarks can be verified and confirmed as the surgical dissection is being done. The brain, the eye, the carotid artery, and the optic nerve are out of harms way. A safe and more thorough dissection allows patients to resolve their chronic structural problems without the worry of brain and eye injury.
Now surgery can be done as an outpatient under general anesthetic, (with the above mentioned technology). It is a good treatment alternative whether you are 8 years old or 80 years old, if you have suffered in with chronic sinus problems that are structural in nature and have failed to resolve with medical treatment.
Specifically, surgery is recommended when patients fail to respond on good, complete medical management. Good, complete medical management is widely debated. It is important for you to realize that nasal/sinus disease, (although miserable, uncomfortable and limits what people would like to do, and when they would like to do it), is rarely life threatening. One has the opportunity of deciding the appropriate treatment plan that seems to make the most sense. Certainly, since it is not a life-threatening illness, one can elect to continue medical therapies, even in view of considerable structural abnormalities. However, when medical therapies have proved to be of very little help, surgery is proven to be a safe and successful option.