Stuart N. Thomas, MD
Central Park Ear, Nose & Throat, LLC
Chronic Rhinosinusitis (CRS), as we currently understand it, is a chronic disease very much like high blood pressure or arthritis in that it is incurable and frequently requires continued, long term therapy to manage the symptoms. We believe CRS to be an exaggerated inflammatory response limited generally to the mucosal lining of the nose and sinuses. The exact cause of this inflammation is controversial and poorly understood but research on this topic is ongoing.
In most cases of CRS, this exaggerated inflammatory response can best be controlled with corticosteroids–either taken orally (systemically) or applied topically (ie–applied directly onto the lining of the sinuses by nasal irrigation,spray, etc). The role of surgery is primarily to create a clear pathway by which to introduce these steroids (and occasionally antibiotics as well) into all the recesses of the sinuses. Applying the steroids topically is felt to be significantly safer over the long term than oral steroids due to a lower rate of absorption into the blood stream. Much like other diseases, there is a spectrum of severity with a few patients having severe cases that are difficult to control with any medications or surgery, a few others with very mild disease easily controlled with surgery alone, but the majority lying somewhere in the middle. Where you lie on this spectrum will take time to fully realize, but some assumptions can be made from your history and CT scans.
Adequate surgical opening of all involved sinuses in a patient with significant or severe CRS frequently requires more than one surgery to achieve. Surgery is performed endoscopically (with small telescopes attached to video cameras–much like knee surgery, gall bladder surgery, etc) through the nose without external incisions and is accordingly referred to as Endoscopic Sinus Surgery (ESS or FESS). Small amounts of sinus mucus membrane and the delicate bony walls between the effected sinuses (as well as any polyps or other infected matter) are removed in an exacting and controlled way, aimed at preserving key components of sinus anatomy while allowing wide access to all the nooks and crannies of the sinus cavities. Frequently, there is also deviation of the nasal septum that limits surgical access to the sinuses on one or both sides. When this is present, Nasal Septal Reconstruction (NSR) is performed at the same time as the ESS.
A fact that cannot be overstressed is that postoperative care is critical to the success of this surgery. This entails both consistent, fairly intensive home therapy (thrice daily saline irrigations followed by some type of steroid instillation) as well as several (exact number of visits depends on your clinical course and initial severity of the disease) follow up appointments–each accompanied by a separately billed procedure: either “nasal endoscopy” with local anesthesia for surveillance (assessment of the progress of the sinuses in healing so as to be able to adjust postop medications) or occasionally, actual “debridements” where debris/scar/polyp tissue is actively cleared from the sinuses in the office, under local anesthesia. These procedures are the key to knowing how to tailor therapy to your specific situation and treatment without them would be akin to driving blindfolded. Depending on your insurance coverage and deductible, the price of these postop procedures may vary. Specifically, the cost of these postoperative in-office procedures will not be covered by the cost of the surgery itself or the office visits, and will be billed at each visit as they are performed.
The good news is that in the last 5-10 years, significant clinical developments have allowed us to do a much better job managing this disease than we ever could previously. This is primarily due to an improved understanding of the role of ESS as well as improved methods of introducing steroids (and antibiotics) in higher concentration directly into the sinuses themselves. It should also be noted that there are a number of intriguing immunological therapies currently being studied, that show promise in more effective control of this disease in the future.
We here at Central Park ENT have many years of combined experience dealing with most diseases of the nose and sinuses. When you come here, you have the advantage of being treated in a group practice–an environment of consultation and shared experience that improves our ability to tailor therapy for all patients. We hope you will allow us to take a role in your treatment and recovery.