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News -> July, 2000 News
Patients who voice the above complaint most often do so to someone other than
their original surgeon. Instead, they are seeking help from another physician
because of their dissatisfaction with sinus surgery. This is not a wonderful
practice-builder. All of us are careful to obtain "informed consent" and
communicate to the patient the potential complications of endoscopic sinus
surgery, such as bleeding, visual loss, and/or CSF leak. A bit more time spent
in making sure that the patient (and surgeon) have realistic expectations of
the benefits of the surgery will be an excellent investment in patient
satisfaction.
What is sinusitis? The diagnostic criteria for sinusitis have been
specifically set out by the AAO-HNS Task Force on Rhinosinusitis. Most of us
recognize and can accurately diagnose the various types of sinusitis (acute,
recurrent, subacute, chronic), but most patients (and some physicians)
characterize every respiratory tract infection as "sinusitis." Before surgery,
the exact problem presented by the patient has to be clarified. It may help to
use printed pamphlets, such as those available from the AAOHNS, or to
formulate a simple patient information sheet for use in your practice. Many
patients equate allergy, upper respiratory infections, headache (of various
causes), cough, and throat-clearing with "sinusitis." The time to educate
them is before surgery, not afterward.
What can be expected from the surgery? Patients unfortunately want the surgeon
to guarantee to them that they will never have another "sinus infection"
again. Rhinologists realize that what surgery can realistically accomplish is
the marsupialization of obstructed sinus outflow tracts and the removal of
irreversibly diseased tissue. After surgery, patients will hopefully recover
in a normal fashion from respiratory infections, with no residual source of
reinfection, but they will not be spared entirely from such infections. Be
sure that patients understand this.
Are there unrecognized contributory factors? Persons chronically exposed to
others with respiratory infections have an increased number of infections
themselves. This group includes health care workers, teachers, daycare
workers, parents and grandparents of small children, and flight crews
Likewise, the presence of factors such as allergy, immune incompetence,
cystic fibrosis, and allergic fungal sinusitis must be considered and dealt
with, since in each case surgery isn't the total answer to the problem.
What has previous surgery accomplished? The most common correctible problems
seen in patients with recurrent difficulties after functional endoscopic sinus
surgery are incomplete resection of the uncinate process and failure to
include the natural ostium of the maxillary sinus in the middle meatal
antrostomy. Also, the formation of synechiae resulting in obstruction of the
outflow tract (most often the frontoethmoid region) can require revision
surgery. These should all be considered when patients have continued
complaints after surgery.
Careful pre-operative attention to promoting patient understanding and
achieving a common ground for expectations will help avoid the post-operative
complaint, "Doc, my sinus surgery didn't work."
Richard L Mabry, MD, Professor
Department of Otolaryngology - Head and Neck Surgery
University of Texas Southwestern Medical Center
Dallas, Texas
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