Oregon Sinus Center - Disorders & Treatment
Disorders of the Nose & Sinus
The Oregon Sinus Center provides care and treatment for a number of nose and sinus problems. Below is a small sample of some of the disorders and treatments related to the nose and sinus. Note: The information contained in these pages is for educational purposes only. It should not be construed as individualized diagnostic and treatment advice. Please contact our clinic to schedule an appointment with one of our providers, if you would like more information about a disorder or treatment, or to be evaluated.
Disorders of the Nose & Sinus
Sinusitis has become a much more common condition in the last twenty years. Today, sinusitis is one of the most common chronic (ongoing) conditions in the United States.
Fifty million Americans, 20% of the nation's population, suffer from sinusitis and many are forced to breathe through their mouth because of the constant stuffy nose. Many people with sinusitis feel there is not much that can be done about this condition and continue to live with it until an uncontrolled increase of the symptoms forces them to get urgent care from a specialist or emergency room.
Sinusitis is often a chronic (ongoing) disease that includes the symptoms of nasal obstruction, chronic nasal drainage, decreased sense of smell, facial pressure, frequent sinus infections, and swelling which can lead to ongoing fatigue, pain in the upper teeth, headaches, and related respiratory problems such as asthma.
There is widespread confusion among patients on whether they suffer from allergies, a common cold, or a sinus condition. Symptoms and signs for each condition differ. Understanding that each one requires a unique treatment regimen helps patients to make an informed choice for the correct medical care.
The various types of sinusitis (allergic, bacterial, or fungal) can require medical treatment, surgical treatment, or both. An otolaryngologist (an ear, nose, and throat doctor) can discuss the latest diagnostic procedures and provide the optimum course of treatment.
Nasal & Sinus Polyps
Polyps are tissue swellings within the nose and sinuses that can be responsible for many of the symptoms described by patients with rhinosinusitis. Polyps may simply block the nasal airway,creating difficulty in nasal breathing, or may block the proper drainage of the sinus cavities leading to infections within the sinus cavities.
Polyps are generally thought to occur as a result of an ongoing inflammatory process within the nose and sinuses. Although this may be related to allergies, most cases of polyps occur as a result of non-allergic processes.
Whatever the cause, polyps can wreck havoc in the nose and sinuses and make patients miserable. Common symptoms in patients with nasal and sinus polyps include nasal obstruction, decreased sense of smell, repeated sinus infections, and a lot of drainage from the nose. Many of these patients feel as though they have a cold all of the time.
If polyps are suspected, the patient may undergo an endoscopic examination in the clinic. This procedure uses a small telescope that is placed inside of the nostril to examine the nose and sinuses. Computed tomography (CT, CAT) scans may help to show the exact location of polyps within these cavities.
After getting the correct diagnosis, a number of medical treatments can be started. These medications may include anti-inflammatory sprays, decongestants, inflammatory mediator inhibitors, and systemic steroid medications. It is important that the physician and patient recognize that medications are often required on a long-term basis in order to reduce polyp size and prevent their re-growth.
In some cases, surgical excision of the polyps is required using a thin telescope (endoscope) which is placed through the nostril in order to visualize the polyps. The sinuses may also be entered in this fashion in an attempt to completely remove polyps. This type of surgery is often referred to as Endoscopic Sinus Surgery.
Following this type of surgery, it is very important to maintain medical treatment and the nose and sinus cavities should be watched carefully to prevent the return of the polyps. In many cases, if a proper medical and surgical treatment plan is carefully followed, patients will not require further surgery on the nose and sinuses to remove polyps.
Our surgeons have a particular interest in patients who have experienced the return of polyps following previous nasal and sinus surgeries. The Oregon Sinus Center actively conducts ongoing research into better treatments for nasal and sinus polyps.
Cerebrospinal Fluid Leak (CSF)
The management of CSF leaks also lends itself to a multidisciplinary approach as well. Most frequently a neurosurgeon is consulted to help with the treatment and care before and during the surgery. In the majority of cases, no external incision is involved and the CSF leak can be managed using a transnasal endoscopic approach. The image guidance system is often helpful here as well for identification of the CSF leak.
Once the leak is identified it is repaired using the patient’s tissue, most commonly bone and soft tissue from the nasal cavity. Typically, the patient stays in the hospital one or two nights before going home.
In addition to the management of chronic sinonasal inflammatory problems the physicians at Oregon Sinus Center are experts in the management of sinonasal tumors.
A multidisciplinary approach is applied to the management of sinonasal tumors to maximize the chances of a long-term cure while minimizing patient risk and deformity. Our skull base surgery team collaborates with our multidisciplinary providers to treat complex tumors of teh nose, sinuses, and skull base.
Other specialties involved in patients care can include brain and spine doctors, eye and eye socket surgeons, facial plastic and reconstructive surgeons, mouth and jaw surgeons, blood experts, cancer doctors, neuroradiology doctors, and radiation oncology doctors. Utilizing the expertise available in these diverse fields, we create a total treatment plan tailored to each patient's needs.
Patients coming to the Oregon Sinus Center with these tumors go through a thorough evaluation. The evaluation before the surgery will include a head and neck exam, a review of the tumor, and a detailed review of the radiographic imaging studies (CT and MRI).
The head and neck exam will include a procedure called nasal endoscopy. The endoscopy allows the doctors to see and map out the tumor with great detail. When combined with the CT and MRI findings a precise "mapping" of the tumor can be accomplished before the surgery.
Depending on the characteristics, location, and size of the tumor, appropriate consultation with the doctors of the specialties noted above is arranged. An plan is then created for each patient.
The management of sinonasal tumors can include surgery and/or radiation therapy. A variety of surgical approaches have been used to access these tumors.
In recent years the development of endoscopic techniques and image guidance systems has led to a less invasive approach to sinonasal tumor excision, without compromise in the long-term cure rates. The visualization and localization information provided by these technologies during the surgery often allows the doctor to completely remove the tumor while minimizing cosmetic deformity, complications, and hospital stay.
The following case demonstrates how a minimally invasive approach is used to treat sinonasal tumors. A 77 year old man came to the Center with complaints of headache, facial pain above and below the eyes, right sided nasal obstruction, decreased smell and nose bleeds. Nasal endoscopy and imaging studies showed a tumor of the right sinonasal cavity. Biopsy of the tumor showed the tumor to be malignant (cancer).
Given the appearance, location, and possible size of the tumor, a specialist consultation was obtained. After a thorough review of the endoscopic and radiographic findings the patient was taken to the operating room where a removal of the tumor was done using the image-guidance system.
No cuts outside the nose were required and the tumor was completely removed. After the surgery, there were no complications and the patient went home the day of surgery. He underwent therapy after the surgery and is tumor free one year after treatment. In the past, the patient would have had an external facial incision and a craniotomy resulting in cosmetic deformity, increased risk, and a prolonged hospital stay. Using the new video technology, and specialists from various departments, we were able to limit the scarring and the cosmetic impact of the surgery.
Smell and Taste Disorders
Disorders of smell and taste can have a large impact on quality of life. Currently about 2 million adults in the United States are evaluated for smell and taste disorders every year, but it is believed many more cases go unreported. It is estimated that up to 80% of taste is a result of olfactory (or smell) input. As a result, loss of smell is frequently interpreted as a loss of taste.
Olfactory (small nerve) cells are stimulated by odors. These nerve cells are found in a tiny patch of tissue located high up in the nose and connect directly to the brain. Taste cells react to food or drink mixed with saliva. The taste cells are located in the taste buds located on the surface of the tongue. These surface cells send taste information to nearby nerve fibers, which send messages to the brain.
The olfactory pathway can be disrupted by conductive (travel) or sensory (feeling) neural causes. Conductive disruptions are caused by nasal air flow obstruction. Examples of these include chronic rhinosinusitis, polyps, allergic rhinitis and tumors. Sensory neural causes occur with damage to the olfactory nerves themselves. Examples of these include loss of smell after an upper respiratory infection, head trauma or other neurological disorders.
Evaluations of these disorders include a thorough history and physical exam with an endoscope, “scratch and sniff” smell testing, taste testing including the sip, spit and rinse, and often imaging usually involving a CT scan.
Treatment of these problems depends on the problem and the severity of the loss. Some losses caused by a medication will recover as soon as the medication is stopped. Many of the conductive causes can be managed with the use of anti-inflammatory medications or surgery if the medical treatments fail. Usually, sensory neural losses do not respond to medical or surgical treatments. Instead, changes over time will indicate improvement.
Some Treatment Options
No matter what the medical problem, surgery is almost always a last resort. Doctors prefer to try less invasive treatments first, such as medication. Most chronic sinus problems are thought to happen as a result of ongoing swelling in the nose and sinuses. In some cases, the cause of the inflammation (swelling) is difficult to determine.
The treatment of chronic sinusitis revolves around re-establishing air flow and drainage of the sinus air spaces. A majority of chronic sinusitis cases are managed medically. Non-surgical options are used as much as possible and may include steroid creams or medications, newer anti-inflammatory agents, decongestants, allergy remedies, and antibiotics. Many patients are treated with antibiotics, although the symptoms will keep happening unless sinus drainage and air flow is somehow fixed and maintained. In most cases, surgical options are considered only if a patient has tried and failed as much medical therapy as is available.
Sinus surgery is performed using endoscopes (small telescopes) to see inside the nose and sinus. Generally, no incisions are required. During surgery, the minimal amount of sinus tissue necessary is removed to re-establish air flow and drainage of the sinus air spaces. This is done in a very precise manner so that healing is quicker and scarring is minimized. Nasal packing (adding material) is generally not necessary.
Patients are instructed in the proper method for irrigating the sinuses after the surgery to have a faster recovery. In addition, close endoscopic monitoring and cleaning of the sinus cavities is required to help prevent the sinus problems from returning.
Medical management such as cream and medical steroids, newer anti-inflammatories, and antibiotics may also be necessary after the surgery to aid in a successful outcome.
Some sinus problems are not caused by an inflammatory disease. Victims of a facial injury may have damage to their sinuses. Additionally, sinus pain can be caused by a non-cancerous or cancerous tumor. In both circumstances, surgical intervention is often necessary.
Computer - Guided Sinus Surgery
The Oregon Sinus Center at OHSU offers an array of new surgical technologies for the treatment of sinusitis. One of the most recent advances is the development of computer-guided sinus surgery. By using a computer workstation in the operating room, surgeons can now see and use 3-dimensional CT scan images of a patient's sinuses during surgery. This interactive surgical device allows identification of critical nasal structures and treatment of diseased areas for the patient with complex sinus disease.
The Oregon Sinus Center surgeons are using this new "STEALTH" technology that guides surgical instruments for potentially more accurate and effective sinus surgery. Because the new procedure is done through an endoscope inserted into the nose, an open incision is rarely necessary.
The new technology, computer image-guided surgery, is used during surgery for severe forms of chronic sinusitis, in cases when previous sinus surgery has altered the nose or sinus cavity, or where a patient's sinus cavity structure is very unusual, making typical surgery difficult. Tumors and cerebrospinal fluid leaks involving the nose and sinuses may also be approached using this technology.
While complications of sinus surgery are very low, unusual nasal structures may put a patient at increased risk for complication. The guided surgery system may help to minimize such risks.
The patient population at the Oregon Sinus Center tends to have severe sinusitis and many have gone through previous sinus surgeries that were not as successful as they had hoped.The image guidance system is utilized in most of these sinus surgeries that are performed by the sinus specialists.
Image guidance is a near-three-dimensional mapping system that combines computed tomography (CT) scans and real-time information about the exact position of surgical instruments using infrared signals. In this way, surgeons can navigate their way through complex sinus passages and provide surgical relief more precisely. Image guidance uses some of the same stealth principles used by the military.
Prior to surgery, an endoscopies used to examine nasal and sinus passages, and CT scans are taken to build a computerized model of the patient's skull. During surgery, the surgeon views a computer monitor where the image guidance system shows the location of the surgical instrument's tip on the CT scans. Tissue that is obstructing the sinuses is surgically removed so that sinuses can drain properly.
Almost all patients go home shortly after surgery and without gauze packing in their noses. The surgical precision of the image guidance system means that less tissue is damaged, so recovery is faster and there is less discomfort than in surgeries that previously required open incisions
One patient's story
One patient struggled through ten years of chronic sinusitis and three sinus surgeries before turning to Dr. Timothy Smith for help. She felt a lot of people had given up on her.
She had been on antibiotics constantly, nearly every month with two weeks on, two weeks off. The strength of the antibiotics was constantly increased. She explained how the use of antibiotics affected her joints.
Her right frontal sinus closed off and nothing would drain. After a while, a membrane grew in the opening, trapping the mucus and causing severe eye pain. Finally, she had 100% blockage that was so close to the brain and eyes, that it was absolutely important that she have surgery right away.
The surgeon explained that opening the membrane could be difficult due to the small space, and because of it being so close to the brain and eyes The image-guided surgery system has been particularly helpful in these situations.
The patient went through the surgery with a normal healing process and no complications. She has been much healthier since this surgery.
See Our Surgeons at Work
Some of our patients come to us with a diagnosis of nasal polyposis. A polyp is swollen tissue that causes difficulty in nasal breathing, and can even block proper drainage pathways within the sinuses, which can in turn lead to infections within the sinus cavities. Many of our patients who come to us with nasal polyps experience nasal obstruction, decreased sense of smell, repeated sinus infections, and a lot of drainage from their nose (feeling like they have a year-round cold).
While the cause of polyps is unknown, there are some medication management options once the diagnosis is confirmed. These options include anti-inflammatory sprays, decongestants, inflammatory mediator inhibitors, and systemic steroid medications.
When medications are not sufficient, patients can undergo endoscopic sinus surgery to remove the polyp, this procedure is called a polypectomy. The surgeon uses a thin telescope (endoscope) which is placed through the nostril to visualize the polyps. The polyps are then removed endoscopically, leaving no external markings of the procedure.
Here is a video of a polypectomy: