My 33-year-old son suffers from severe allergies. Since November, he has had severe sinusitis. After an MRI showed total blockage of his sinuses --"totally diseased," according to his allergy doctor -- he has been referred to an ENT for orthoscopic surgery on all four sinus cavities. What does such surgery entail? What will he experience after surgery? How long will normal recovery take? What is the success rate with this surgery?

J.K.H.

Before answering your questions, I have a few random comments:

• Sinus operations in patients with "severe allergies" are doomed to failure unless the allergies are aggressively managed. If he is not already involved in desensitization ("allergy shots"), he needs to be, prior to any sinus operation he may need.
  
• MRI is a lousy study to assess sinus disease, since it exaggerates the extent of disease. The ENT will probably insist on obtaining a sinus CT scan, and rightly so. Only a sinus CT can provide an accurate assessment of sinus disease, and only a sinus CT can provide the detailed picture of bony anatomy that is vital to surgical planning. (This CT is our "road map.")
  
• Regardless of the wishes of your son's allergist, it is the ENT's decision whether or not to recommend surgery. The doc who holds the knife makes the call, NOT the referring doctor.
  

On to your questions.

First, some quibbles on terminology and facts that you must have picked up from the allergist. Sinus surgery is "endoscopic," not orthoscopic. Endoscopes are rigid, slender fiberoptic telescopes that give the surgeon a magnified view of the nasal and sinus cavities during the operation. Also, there are not four sinus cavities -- four regions, perhaps, but not four cavities. The maxillary and sphenoid sinuses are often partitioned, and the ethmoids are a veritable honeycomb of tiny cavities.

Phew. Glad I got that off my chest. Here's what endoscopic sinus surgery (ESS, also referred to as FESS; the F stands for "functional") entails: it is almost always day surgery, meaning he will not need to stay overnight. It can be performed under local or general anesthesia, in accordance with the surgeon's preference. During the operation, the surgeon will use the endoscopes to view the anatomy, while using specially designed instruments for irrigating (rinsing), suctioning and dissecting the sinus tissues. The surgeon's goal is to eradicate disease and enlarge natural drainage pathways, with the hope of preventing (or reducing the severity of) future sinus infections.

There should be no facial consequences after a FESS; black eyes are fairly rare. Pain is usually mild. Although some folks complain bitterly of nasal pain, this is rare in my experience. Some degree of oozing (bloody fluid dripping from the nose, and/or running down the back of the throat) is normal and may persist for a few days after the operation. Bloody crusts may form within the nose. This can persist for even a few weeks after surgery. Irrigation of the nasal cavity (for example, with saline) is preferred by most sinus surgeons as a method to reduce or eliminate these crusts and improve healing. In other words, your son may have to wash his nose regularly after the operation.

Success rate? Much depends upon your son's expectations. If he expects this operation to once-and-for-all-time eradicate all of his nasal and sinus problems, then he will probably be sorely disappointed. On the other hand, if he merely expects some relief, he will probably be delighted with the results. I usually tell people the following: "Most people, following this operation, will tell you that they are happy with the results and would do it again, but they are still bothered by symptoms A, B and C." In other words, FESS is far from being a perfect operation. It should be reserved for patients with clear-cut anatomical problems or patients who have had aggressive and thorough medical treatment to no avail.